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FSAI Incident Report Form

FSAI Incident Report Form

For Industry and Agency Use Only

This form is for industry and agency personnel only. Consumers should use our ‘ Make a Complaint’ form

Fields marked with * are mandatory.

Name: *

Position: *

Organisation: *

Address: *

Direct telephone:

Out of hours telephone:

Fax no:

Email: *

Send to a colleagues email:

entering multiple emails, please separate with a ;

Section 1: Details of Hazard

Description of hazard: *

Date hazard was identified:

How hazard was identified:

Details of any associated illness:

Section 2: Details of Food

Product name (on label):

Brand name:

Food Type:

Does food require cooking prior to consumption?:

Is it an ambient, chilled or frozen food?:

Lot/Batch number:

Durability Details (Use by/Best Before date):

Identification marks/stamps/ premises approval number:

Date of Production (if known):

Quantity of Food Implicated (if known):

Was the food sold loose, or pre-packed?:

Details of Packaging (pack size/type etc.):

Any other relevant labelling information:

Note: If possible, please email a picture or copy of the product label to foodincidents@fsai.ie, or fax to 01 871301 (marked: FAO Food Incidents).

Section 3: Details of Traceability

Manufacturer name and address:

Retailer name and address:

Supplier name and address:

Importer name and address:

Known distribution:

Has the food been exported (including to Northern Ireland)? Give details?

Country of Origin:

Section 4: Details of Testing

Was any testing carried out?:

Details and number of samples tested (including any control samples):

Name and address of laboratory:

Is a laboratory report available?:

If pending, state when report is due to be issued:

Note: Please email a copy of the laboratory report to foodincidents@fsai.ie, or fax to 01 871301 (marked: Food Incidents).

Is the laboratory accredited for the used test method?

Section 5: Details of Action Taken

Details of any investigation:

Details of action taken such as: trade withdrawal, customer recall, point-of-sale notice, press advertisement, etc.

Note: Please email a copy of the notice(s) to foodincidents@fsai.ie, or fax to 01 871301 (marked: Food Incidents).

Summary of any contact with other agencies/organisations/ retailers/ manufacturers/distributors:

Details of individuals which were contacted including email address, phone numbers.

Section 6: Other Information

Any other details known relevant to the incident:

Note: When you submit this form it is sent to foodincidents@fsai.ie. The FSAI Food Incidents team will acknowledge receipt. If no acknowledgment is forthcoming please telephone FSAI on 01 8171300 or out of hours, in an emergency, please telephone 01 685 6555.

Contact Details

Email: foodincidents@fsai.ie
Fax: 01 817 1301 (For attention of Food Incidents)
Phone: 01 817 1300 and advise information is being sent.

Out of Office/Emergency Contact Details

Phone: 01 685 6555 and advise information is being sent.

Last reviewed: 1/6/2017

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FSAI Incident Report Form

For Industry and Agency Use Only

Section 1: Details of Hazard

Section 2: Details of Food

Section 3: Details of Traceability

Section 4: Details of Testing

Section 5: Details of Action Taken

Section 6: Other Information

Contact Details

Out of Office/Emergency Contact Details

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