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U.S. Department of Health and Human Services

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FDA Forms

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Form Date Food and Drug Administration Forms Format Contact Info
0421  07/2003 Sample Accountability Record (ORA) (PDF)  (PDF - 389KB) At the warehouse
formsmanager@OC.FDA.GOV
0431  09/2010 Analyst Worksheet (ORA) (PDF)  (PDF - 547KB) William Campanaro
240 821 6667
0431a  05/1984 General Continuation Sheet (PDF)  (PDF - 722KB) William Campanaro
240 821 6667
0431d  08/2012 Bacteriological Record (PDF)  (PDF - 1.2MB) William Campanaro
240 821 6667
0431e  09/2011 Industrial Chemicals Worksheet (PDF)  (PDF - 389KB) William Campanaro
240 821 6667
0431f  11/1989 Quantity of Contents (PDF)  (PDF - 337KB) William Campanaro
240 821 6667
0431j  08/1985 Botulism Continuation Sheet (PDF)  (PDF - 6KB) William Campanaro
301-827-1036
0431k  08/1985 Shellfish Bacteriological Record (PDF)  (PDF - 8KB) William Campanaro
301-827-1036
0431m  12/1979 Elemental Analysis Worksheet (PDF)  (PDF - 6KB) William Campanaro
240 821 6667
0433  06/1982 Tomato Inspection Report (PDF)  (PDF - 12KB) Rina Bhikha
301-796-5483
0465  08/1985 Sample Summary (DOC)  (PDF - 221KB) William Campanaro
240 821 6667
0766  06/2014 Application for Authorization to Re label or to Perform Other Action of the Federal Food, Drug, and Cosmetic Act and Other Related Acts (PDF)  (PDF - 647KB) Domenic Veneziano
301-443-6553
1533  10/2001 Results of Sediment Pad Grading (PDF)  (PDF - 268KB) Rina Bhikha
301-796-5483
1551  05/2011 Report of Sample Analysis (PDF)  (PDF - 353KB) William Campanaro
240 821 6667
1551b  01/1993 Report of Sample Analysis (Aflatoxins) (PDF)  (PDF - 337KB) William Campanaro
240 821 6667
1570  04/1978 Summary of Bacteriological Results (PDF)  (PDF - 302KB) William Campanaro
240 821 6667
1609  03/1986 Research Project Record (PDF)  (PDF - 337KB) William Campanaro
301-827-1036
1609a  03/1986 Research Progress Record (PDF)  (PDF - 349KB) William Campanaro
301-827-1036
2359o  10/2013 Permission for Publication Interstate Milk Shipper’s Listing (PDF)  (PDF - 660KB) Robert Hennes
240-402-2175
2400  03/2001 Cultural Procedures - General Requirements (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400a  03/2001 Milk Laboratory Evaluation Form: Standard Plate Count, Coliform, and Simplified Count Methods (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400a-1  03/2001 Milk Laboratory Evaluation Form: Spiral Plate Count Methods (PDF)  (PDF - 85KB) William W. Northeimer, Ph.D.
708-924-0629
2400b-1  03/2001 MLEF Detection of Inhibitory Substances in Milk Bacillus Stearothermophilus (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400b-3  03/2001 MLEF Detection of Inhibitory Substances in Milk Delvotest 5 Pack (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400d  03/2001 MLEF Direct Microscopic Somatic Cell Count (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400h  03/2001 Optical Somatic Cell Count (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400h-1  03/2001 MLEF Electronic Somatic Cell Count Foss 250/300/360/400 (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400h-2  03/2001 MLEF Electronic Somatic Cell Count Bentley Somacount 150/300/500 (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400h-3  03/2001 MLEF Electronic Somatic Cell Count Fossmatic 5000 (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400i  03/2001 Pasteurized Milk Containers (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400j  03/2001 Phosphatase Test (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2400k  03/2001 MLEF Flat Lid Methods (PDF)  (PDF - 68KB) William W. Northeimer, Ph.D.
708-924-0629
2400l  03/2001 MLEF Disintegration Method for Paper, etc. (PDF)  (PDF - 45KB) William W. Northeimer, Ph.D.
708-924-0629
2400m  03/2001 MLEF Dairy Waters (PDF)  (PDF - 8KB) William W. Northeimer, Ph.D.
708-924-0629
2589  08/2001 Inspection Summary - Bus Service Area Sanitation (PDF)  (PDF - 380KB) Rina Bhikha
301-796-5483
2591  08/2001 Inspection Summary Equipment Evaluation (PDF)  (PDF - 378KB) Bruce Kummer
240-402-2142
2679  08/2001 Food Warehouse Inspection Report (PDF)  (PDF - 281KB) Maya Johnson-Nimo
301-827-2906
2681  02/2002 Bakery Inspection Report (PDF)  (PDF - 879KB) Maya Johnson-Nimo
301-827-2906
2682  10/1988 Beverage Plant Inspection Report (PDF)  (PDF - 857KB) At the warehouse
formsmanager@OC.FDA.GOV
2684  10/2012 State Contract Monthly Food Report (PDF)  (PDF - 376KB) Wendy Campbell
615-310-0483
2684a  04/2011 State Contract Monthly Feed Establishment Report (PDF)  (PDF - 374KB) Wendy Campbell
615-310-0483
2782  09/1998 Field Test Record Continuation Sheet (PDF)  (PDF - 1MB) Nick Walker
301-796-5910
2783  10/1980 Mobile Radiographic Systems Field Test Record (PDF)  (PDF - 19KB) Nick Walker
301-796-5910
2784  10/1980 Above Table X-Ray Source Radiographic Systems (PDF)  (PDF - 30KB) Nick Walker
301-796-5910
2785  05/1982 Dental Radiographic Systems Field Test Record (PDF)  (PDF - 21KB) Nick Walker
301-796-5910
2786  05/1982 Under Table X-Ray Source Fluoroscopic & Spot Film Systems Field Test Record (PDF)  (PDF - 30KB) Nick Walker
301-796-5910
2814  08/1993 Field Equipment Request (PDF)  (PDF - 1.1MB) William Campanaro
301-827-1086
2966  03/2013 Food GMP Inspection Report (PDF)  (PDF - 893KB) Wendy Campbell
615-310-0483
3068  08/1992 Peak Kilovoltage Determination Field Test Record (PDF)  (PDF - 57KB) Nick Walker
301-796-5910
3069  10/1980 Above Table X-Ray Source Fluoroscopic & Spot Film Systems Field Test Record (PDF)  (PDF - 19KB) Nick Walker
301-796-5910
3071  04/2001 General Information Field Test Record (PDF)  (PDF - 20KB) Nick Walker
301-796-5910
3260  02/1983 C-Arm Fluoroscopic & Spot-Film Systems Field Test Record (PDF)  (PDF - 41KB) Nick Walker
301-796-5910
3261  02/1983 Vertical Mount Cassette Holder Radiographic Systems Field Test Record (PDF)  (PDF - 23KB) Nick Walker
301-796-5910
3297  04/1984 Head and Neck Radiographic Systems Field Test Record (PDF)  (PDF - 29KB) Nick Walker
301-796-5910
3500  02/2013 MedWatch: The FDA Safety Information and Adverse Reporting Program (PDF)  (PDF - 1.6MB) MEDWATCH
1-800-FDA-1088
3500A  02/2013 MedWatch: The FDA Safety Information and Adverse Event Reporting Program - Mandatory (PDF)  (PDF - 1.3MB) MEDWATCH
1-800-FDA-1088
3500A  02/2013 MedWatch: The FDA Safety Information and Adverse Event Reporting Program - Mandatory (Instructions)  (PDF - 217KB) MedWatch
1-800-332-1088
3500B  04/2013 MEDWATCH Consumer Voluntary Reporting (PDF)  (PDF - 1.2MB) MEDWATCH Saftey Alerts
1-800-FDA-1088
3511  07/2010 FDA LACF Inspection Report (PDF)  (PDF - 649KB) Bob Nelligan
706-485-2725
3511-2  07/2010 FDA Acidified Food Inspection Report (PDF)  (PDF - 465KB) Bob Nelligan
706-485-2725
3511-3  07/2010 Aseptic Processing & Packaging Report (PDF)  (PDF - 727KB) Bob Nelligan
706-485-2725
3511a  03/2014 Processing in Steam in Still Retorts (PDF)  (PDF - 914KB) Bob Nelligan
706-485-2725
3511a-1  03/2014 Processing in Steam in Crateless Retorts (PDF)  (PDF - 1004KB) Bob Nelligan
706-485-2725
3511b  03/2014 Processing in Water in Still Retorts (PDF)  (PDF - 935KB) Bob Nelligan
706-485-2725
3511c  03/2014 Processing in Steam in Continuous Agitating Retorts (PDF)  (PDF - 966KB) Bob Nelligan
706-485-2725
3511d  03/2014 Processing in Steam in Discontinuous Agitating Retorts (PDF)  (PDF - 876KB) Bob Nelligan
706-485-2725
3511e  03/2014 Processing in Water in Discontinuous Agitating Retorts (PDF)  (PDF - 972KB) Bob Nelligan
706-485-2725
3511f  05/2014 Processing in Steam in Hydrostatic Retorts (PDF)  (PDF - 844KB) Bob Nelligan
706-485-2725
3511g  01/2011 Processing in Cascading/Spray Water Retort (PDF)  (PDF - 697KB) Bob Nelligan
706-485-2725
3511h  01/2011 Processing in Steam-Air Retorts (PDF)  (PDF - 674KB) Bob Nelligan
706-485-2725
3511i  12/2013 Processing in Other Unique Retort Systems (PDF)  (PDF - 926KB) Bob Nelligan
706-485-2725
3610  10/2003 Contract Audit (PDF)  (PDF - 540KB) Catherine Hosman
781-587-7443
3611  09/2003 Audit Report (PDF)  (PDF - 353KB) Caleb Michaud
301-796-5932
3613b  03/2012 Supplementary Information Certificate of a Pharmaceutical Product (PDF)  (PDF - 585KB) Import/Export Team
CBER 301-827-6201 or
CDRH 301-796-7400 or
CVM 240-276-9227.
3623  11/2005 Farm Investigation Questionnaire (PDF)  (PDF - 662KB) Rina Bhikha
301-796-5483
3623a  11/2005 Additional Water Sources (PDF)  (PDF - 191KB) Rina Bhikha
301-796-5483
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