Free fda-2684.xft - Federal

CONTRACT NUMBER

STATE CONTRACT MONTHLY FOOD REPORT
DATE INSTRUCTIONS

NAME

STATE AND AGENCY PREPARED BY: REPORTING PERIOD Follow detailed instructions on back of this page. Reports are due on the last working day of the following month. Negative reports are required.

a. TOTAL INSPECTIONS

b. ROUTINE INSPECTIONS 1. INSPECTIONS ACCOMPLISHED c. REINSPECTIONS (Follow-ups to violative inspections)

d. VISITS (Out-of-Business, etc.)

a. TOTAL SAMPLES COLLECTED

b. NUMBER EXAMINED

2. SAMPLES

c. NUMBER OF DETERMINATIONS

(1) IN COMPLIANCE d. CLASSIFICATION (2) NOT IN COMPLIANCE

a. WARNING LETTERS

b. EMBARGOES/SEIZURES

3. COMPLIANCE ACTIONS c. HEARINGS CONDUCTED

d. PROSECUTIONS/INJUNCTIONS

e. OTHER ACTIONS (Specify type)

4. HIGHLIGHTS AND PROBLEMS ENCOUNTERED. FORM FDA 2684 (4/02)

On an attached sheet of paper, write a brief narrative detailing any major actions occuring, corrections achieved, problems with contract operations, work, etc.

PREVIOUS EDITION IS OBSOLETE

FORM FDA 2684 (4/02)

PREVIOUS EDITION IS OBSOLETE

INSTRUCTIONS FOR COMPLETING FORM FDA 2684 (3/87)
1. Inspections Accomplished - Report total inspections for month, and a breakout by routine, etc., inspections. The sum of b + c + d must equal the total number of inspections reported. Line "d", 'Visits" are reported when an inspection cannot be completed because an establishment is found to be out-of-business, not Official Establishment Inventory (OEI), or inactive.

2. 3.

Samples - Breakout data for total number of samples reported in that month. Compliance Actions - Taken as a result of contract inspections. a. Warning Letters - Include all letters and notices sent to a firms' management informing or warning them of adverse conditions found during an inspection. Embargoes/Seizures - Number of actions taken in conjunction with inspections, which withhold or remove merchandise from the market. Hearings Conducted - Number held as a result of inspections. Prosecutions/Injunctions - Include court actions, i.e., prosecutions, and injunctions. Report number when action filed. Include summary of results on continuation sheet upon completing of action, but do not count again. Other Actions - Actions not fitting above categories (i.e. recalls, license suspensions, administrative penalties) should be reported here and type of action(s) should be specified.

b.

c. d.

4.

Reporting - Include with this report a list of the establishments inspected, indicating firm name, city, date inspected and number of samples collected. Submit the original to FDA District Office with copies to: Food and Drug Administration Division of Federal-State Relations (HFC-150) 5600 Fishers Lane, Rm. 12-07 Rockville, Maryland 20857 and Food and Drug Administration ORA Contract Support Branch (HFA-521) 5600 Fishers Lane, FHSL, Rm. 2108 Rockville, Maryland 20857