USDA FOODS COMPLAINT A: TDA OFFICE USE ONLY Customer Number: Subject: Order Number: 4000578 Texas Department of Agriculture Example: 50000XXXXX Product Description: Incident Date: Date Warehouse Rec’d (mm/dd/yyyy) Example: Fat free Potato Wedges USDA Food: (mm/dd/yyyy) Warehouse Number: Amount of Products Remaining/Hold at Warehouse: B: PRODUCT INFORMATION Warehouse Name Sales Order Number: Box Number: Can Codes: 2.. 3. 4. and City: (for Direct Ship only) Pack Date: Amount of Product Date Warehouse Date Product Rec’d by 5. 6. 7. 8. (mm/dd/yyyy) Received: Shipped Product to CE: (mm/dd/yyyy) Contracting Entity (CE): (mm/dd/yyyy) Injury from Product Photo/Picture 9. 10. upon Receipt from Attached: Warehouse: No Yes No Yes C: COMPLAINANT INFORMATION. Examples: Contracting Entity (CE), Recipient Agency (RA), or Warehouse Enter contact information below: Contact Name: Contact Organization: Phone & Fax No: Email: 11. 12. 13. 14. Example: ABC ISD Description of Complaint/Incident: 15.
USDA FOODS COMPLAINT A: TDA OFFICE USE ONLY Customer Number: 4000578 Subject: Texas Department of Agriculture Order Number: Example: 50000XXXXX Product Description: Example: Fat free Potato Wedges Incident Date: (mm/dd/yyyy) Date Warehouse Rec’d USDA Food: (mm/dd/yyyy) Warehouse Number: Amount of Products Remaining/Hold at Warehouse: B: PRODUCT INFORMATION Warehouse Name and City: 2.. Sales Order Number: (for Direct Ship only) 3. Box Number: 4. Can Codes: 5. Pack Date: (mm/dd/yyyy) 6. Amount of Product Received: 7. Date Warehouse Shipped Product to Contracting Entity (CE): (mm/dd/yyyy) 8. Date Product Rec’d by CE: (mm/dd/yyyy) 9. Injury from Product upon Receipt from Warehouse: Yes No 10. Photo/Picture Attached: Yes No C: COMPLAINANT INFORMATION. Examples: Contracting Entity (CE), Recipient Agency (RA), or Warehouse Enter contact information below: 11. Contact Name: 12. Contact Organization: Example: ABC ISD 13. Phone & Fax No: 14. Email: 15. Description of Complaint/Incident:
USDA%20Foods%20Complaint_V100_131115.docx