Sample Recall Return Response Form

Please check ALL appropriate boxes.

Yes / NoI have read and understand the recall instructions provided in the February 23rd letter.

Yes / NoI have checked my stock and have quarantined inventory consisting of: units

Yes / NoAny adverse events associated with recalled product?
If yes, please explain:


Customer Notification:
Yes / NoI have identified and notified my customers that were shipped or may have been shipped this product by:
DateMethod

< OR >

Yes / NoI am sending a list of customers who received/may have received this product. Please
notify my customers.


Disposition of recalled product:
DateQuantityMethod
Returned:
Destroyed:
Relabeled:
Quarantined:
(pending correction)


Your Information:

Please check the appropriate box(es) to describe your business:
Wholesaler/distributor
Retailer
Grocery corporate headquarters
Food service/restaurant
Repacker
Manufacturer
Other:

Name:
Title:
Telephone number:
(area code first)		 -
Email address:
Firm name:
Street address:
City:
State:
Zip code: