Indiana Department of Education
Food Distribution Program
115 West Washington Street, Suite 600
Indianapolis, IN 46204
Phone: 317-234-2516
Fax: 317-232-0855

LOSS/DISPOSAL FORM FOR USDA FOODS

METHOD OF DISPOSAL FOR USDA FOODS

1.	When you discover out-of-condition USDA foods, before taking any action, contact our office to report the problem.  We will advise you as to what to do with the food in question.

2.	Complete the following form.

3.	The form must be signed and dated by the Food Service Director/Manager and a witness.

4.	To dispose of the USDA food, please do the following:

a.	Open the cans or bags of food and empty the contents into a garbage bag and pour bleach on the contents.

	b.	The empty cans or bags should be placed in another garbage bag or in recycling.

	c.	Dispose of the garbage bag(s) in your dumpster.

4.	Make a copy of the completed form.  Keep the original for your records and email copy to cmoore@doe.in.gov. 

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LOSS/DISPOSAL FORM FOR USDA FOODS

Name of Recipient Agency:  	

RA School Corporation Number: __________________________________________________

Address:

Telephone:

Name of Food Service Manager:

Date of Disposal:

ITEMS DISPOSED OF	
Quantity	Food Items	Date Received	Package Date	Lot Number
(Found on outside of cases)	Sales Order Number
(Usually starts with 5000)	

						

						

Reason for Disposal:  
(Please state reason for disposal for each item.  Specify the kind of spoilage found.)

Product loss covered by insurance?

Freezer: have an alarm system, who does alarm alert, submit copy of temp chart, other info

Refrigerator: alarm, alarm procedure, monitored, submit temp chart, other info

Dry goods: explain damage and past prevention methods.

Explain any improvements made to help prevent future product loss.

Please provide photos which will illustrate the issue, include product labels, lot codes and dates.

Signatures:

Food Service Director/Manager:  _______________________________	

Title: ______________________	Email Address:__________________________   Date:_________

Witness: ___________________________________

Title:  _________________________   Email Address:___________________
Date:   _________