Food Investigation Response Manual
Appendix 6B - Example Template - Effectiveness Checks for Food Recall Form

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Page space of space
Class: space Public Health Unit: space Inspector's Name: space
Name of Recalling Firm: space Product Information: space Recall Reason: space
1.
Name and Address of Food Premise (with City/Town)
2.
Date of Visit
(yyyy/mm/dd)
3.
Contact Name and Phone Number
4.
Notification Received from Recalling Firm/Supplier (Y/N)
5.
Supplier's Name and Phone Number
6.
Recalled product offered for sale at time of visit (Y/N) (If yes, how many?)
7.
If offered for sale, date of notification to the CFIA (yyyy/mm/dd)
8.
If not offered for sale, indicate disposition of recalled product by food premise:
  1. segregated by retailer
  2. returned to supplier
  3. sold out at time of recall
  4. did not receive the product
9.
Distributes further (Y/N) (If yes, notify the CFIA and obtain list)

Notes / Other comments:

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