Complaint Information 2008–2009

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					                     Complaint Information 2008–2009
           Regarding Complaints on USDA-Donated Commodities

     COMMODITY NAME AND CODE:                         _____________________________
Recipient Agency (RA) Name:
School Agreement No.:
City:                                                      State: IL Zip Code:
Contact Person:                                            Phone No.:
Title:                                                     Fax No.:
Email:                                                     Date Complaint Filed:
                                    Reason For Complaint
Description of Problem/Complaint:

1.       Seeking Replacement
2.       Vendor Response Requested
3.       Isolated Incident, Notify Vendor
4.       For Information Only
5.       Other: (Fill In Remarks)
                 Important Information Needed to Research Complaint
                      (Please fill in as much information as possible)
Contract No.       Can Codes             Pack Date    Box No.       Injury From Product
                                                                            Yes     No
Lot No.            No. of Cases Rec'd       Date Product Rec'd By RA:
                                            Product on Hold at RA site:   Yes      No
Amount of Product Remaining at RA site: No. of cases
Physical Location of Product on Hold:
Vendor (If Known):
Other Information:
Delivery Order No. (ISBE use only):
Date Product Rec'd By State Distributing Agency (ISBE use only):

                                        Please fax to 217-782-4550.