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
2 digit month, 2 digit day, 4 digit yearDate
Date and Time of Incident:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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)
Does the equipment have an alarm system?
Who does it alert?
Do you have a temperature log:
Will the item(s) be disposed of:
If yes, how will the item(s) be disposed:
Will you be filing a claim with your school’s insurance company regarding this loss?
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: