USDA Foods Loss Report

Created for Cheryl Moore by Don Gilroy on 06/07/2023.
Indiana Department of Education
USDA Foods Distribution Program
USDA Foods Loss Report

100 North Senate Avenue, Ste. 900
Indianapolis, IN 46204
Phone: 317-234-2516
Fax: 317-232-0855
Contact cmoore@doe.in.gov with questions.

Complete within five (5) business days of loss.
Today’s Date:*

MonthDayYear
Date
Date and Time of Incident:*

MonthDayYear
Date
Hour MinutesAM/PM Option
School Food Authority Full Name:*
School Corporation #*
School Site# where loss occurred*
School Site Name where loss occurred:*
School Site Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number:*
Please enter a valid phone number.
Name of Person Completing Form:*

First NameLast Name
Title of Person Completing Form:*
Phone Number of Person completing form:*
Please enter a valid phone number.
Email of Person completing form:*

Confirmation Emailexample@example.com
Foods Loss: Note: table scrolls to the right. Add additional rows as needed.*
Reason for Loss (Check All That Apply)*

Freezer/Equipment MalfunctionStorage IssueInfestation FloodingTheftFood out-of-condition
Does the equipment have an alarm system?*

YesNo
Who does it alert?
Do you have a temperature log:*

YesNo
Will the item(s) be disposed of:*

YesNo
If yes, how will the item(s) be disposed:
Will you be filing a claim with your school’s insurance company regarding this loss?*

YesNo
Please provide an explanation for the loss:*
Please attach the following documentation (if applicable):

Health Department Destruction Report
Repair Invoices
Temperature Logs
Police Report (if theft)
Pest Control Records
Upload attachments:

Cancelof
Please provide photos, product labels, lot codes and any dates available.

Cancelof
Should be Empty: