Feed Incident Form example Which of the following best describes you? - Select - Consumer Livestock Feed Report Consumer Pet Food Report Industry Inspection Activities Report Veterinarian Livestock Feed Report Veterinarian Pet Food Report None of these Describes Me What type of report are you submitting? - Select - Adverse Event Industry Complaint Product Problem Are you the animal owner? - None - Yes No If you are not the animal owner, who is? (Include, name, address, and phone number) Your Contact Information Name First Last Email Address Address Address 2 City/Town State/Province - Select - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Primary Phone Secondary Phone What is your preferred method of contact? - Select - Address Email Phone Describe in detail what happened and the events that took place: Date problem/symptoms first observed Today's Date Outcome to date: - Select - Recovered completely Better/Improved/Recovering Stable Worse/Declining/Deteriorating Died naturally Died euthanized Unknown Not applicable Other If the animal recovered or death occurred, what date: If the animal(s) died, what was done with the remains: Animal Information Number of animals given product(s) Number of symptomatic animals Species of animal(s) - None - Amphibian Cat Cattle Chicken Deer Dog Fish Goat Horse Other Bird Other Mammal Rabbit Reptile Rodent Breed Age Weight Gender - None - Female Male Mixed Population Unknown Prior to the event, what was the animal’s overall health? - None - Excellent Good Fair List medications the animal was given within 30 days prior to the event: What areas has the animal(s) accessed within 30 days prior to the event? - None - Barn Boarding kennel Cage/tank Dumpsites Fenced pasture Fenced yard Free range Indoors Park/neighborhood walks Veterianrian's office Water ways (stream, ponds, etc.) Unknown Other (Select one of the following) What food has the animal consumed within 30 days prior to the event? - None - Animal killed (rodent, insects, etc.) Feed mill or store purchased animal food Grazing Human food On farm or homemade animal food Raw meat Raw milk (not from the animal's mother) Unknown Other (Select one of the following) What water has the animal consumed within 30 days prior to the event? - None - Bottle water City water Lake water Pond water Rain pool water Spring water Stream water Well water Unknown Other (Select one of the following) Within 30 days prior to the event List medications the animal was given: What areas has the animal(s) accessed? - None - Barn Boarding kennel Cage/tank Dumpsites Fenced pasture Fenced yard Free range Indoors Park/neighborhood walks Veterianrian's office Water ways (stream, ponds, etc.) Unknown Other What food has the animal consumed? - None - Animal killed (rodent, insects, etc.) Feed mill or store purchased animal food Grazing Human food On farm or homemade animal food Raw meat Raw milk (not from the animal's mother) Unknown Other What water has the animal consumed? - None - Bottle water City water Lake water Pond water Rain pool water Spring water Stream water Well water Unknown Other Veterinary Information A description of the section goes here. Was the animal(s) observed by a veterinarian - None - Yes No Veterinarian’s Office Veterinarian’s Name Veterinarian's Address Address Address 2 City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Date of first visit, relating to this incident Date of last visit Diagnosis Does the veterinarian suspect the animal’s food caused the event? - None - Yes No Possible Unknown Describe any other information about the veterinarian’s diagnosis, test results, treatment, suspected cause of the event, etc. If the animal(s) was observed by any additional veterinarians, list their information here Product Information Have you changed the animal(s)’s diet or food within 30 days prior to the event? - None - Yes No If yes, what is the previous product and current product information: Previous Product Information Product Brand Name – Previous: Style/Flavor - Previous: Lot Number - Previous: Manufacturer/Guarantor - Previous Product Address City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Attach a File: Previous Product Image #1 One file only.256 MB limit.Allowed types: gif jpg jpeg png. Attach a File: Previous Product Image #2 One file only.256 MB limit.Allowed types: gif jpg jpeg png. Current Product Information Product Brand Name - Current: Style/Flavor - Current: Lot Number - Current: Manufacturer/Guarantor - Current Product Address City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Attach a File: Current Product Image #1 One file only.256 MB limit.Allowed types: gif jpg jpeg png. Attach a File: Current Product Image #2 One file only.256 MB limit.Allowed types: gif jpg jpeg png. *Do NOT throw any remaining product away until after an investigation by GDA has been performed* Describe any other details surrounding the complaint CAPTCHA
example Which of the following best describes you? - Select - Consumer Livestock Feed Report Consumer Pet Food Report Industry Inspection Activities Report Veterinarian Livestock Feed Report Veterinarian Pet Food Report None of these Describes Me What type of report are you submitting? - Select - Adverse Event Industry Complaint Product Problem Are you the animal owner? - None - Yes No If you are not the animal owner, who is? (Include, name, address, and phone number) Your Contact Information Name First Last Email Address Address Address 2 City/Town State/Province - Select - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Primary Phone Secondary Phone What is your preferred method of contact? - Select - Address Email Phone Describe in detail what happened and the events that took place: Date problem/symptoms first observed Today's Date Outcome to date: - Select - Recovered completely Better/Improved/Recovering Stable Worse/Declining/Deteriorating Died naturally Died euthanized Unknown Not applicable Other If the animal recovered or death occurred, what date: If the animal(s) died, what was done with the remains: Animal Information Number of animals given product(s) Number of symptomatic animals Species of animal(s) - None - Amphibian Cat Cattle Chicken Deer Dog Fish Goat Horse Other Bird Other Mammal Rabbit Reptile Rodent Breed Age Weight Gender - None - Female Male Mixed Population Unknown Prior to the event, what was the animal’s overall health? - None - Excellent Good Fair List medications the animal was given within 30 days prior to the event: What areas has the animal(s) accessed within 30 days prior to the event? - None - Barn Boarding kennel Cage/tank Dumpsites Fenced pasture Fenced yard Free range Indoors Park/neighborhood walks Veterianrian's office Water ways (stream, ponds, etc.) Unknown Other (Select one of the following) What food has the animal consumed within 30 days prior to the event? - None - Animal killed (rodent, insects, etc.) Feed mill or store purchased animal food Grazing Human food On farm or homemade animal food Raw meat Raw milk (not from the animal's mother) Unknown Other (Select one of the following) What water has the animal consumed within 30 days prior to the event? - None - Bottle water City water Lake water Pond water Rain pool water Spring water Stream water Well water Unknown Other (Select one of the following) Within 30 days prior to the event List medications the animal was given: What areas has the animal(s) accessed? - None - Barn Boarding kennel Cage/tank Dumpsites Fenced pasture Fenced yard Free range Indoors Park/neighborhood walks Veterianrian's office Water ways (stream, ponds, etc.) Unknown Other What food has the animal consumed? - None - Animal killed (rodent, insects, etc.) Feed mill or store purchased animal food Grazing Human food On farm or homemade animal food Raw meat Raw milk (not from the animal's mother) Unknown Other What water has the animal consumed? - None - Bottle water City water Lake water Pond water Rain pool water Spring water Stream water Well water Unknown Other Veterinary Information A description of the section goes here. Was the animal(s) observed by a veterinarian - None - Yes No Veterinarian’s Office Veterinarian’s Name Veterinarian's Address Address Address 2 City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Date of first visit, relating to this incident Date of last visit Diagnosis Does the veterinarian suspect the animal’s food caused the event? - None - Yes No Possible Unknown Describe any other information about the veterinarian’s diagnosis, test results, treatment, suspected cause of the event, etc. If the animal(s) was observed by any additional veterinarians, list their information here Product Information Have you changed the animal(s)’s diet or food within 30 days prior to the event? - None - Yes No If yes, what is the previous product and current product information: Previous Product Information Product Brand Name – Previous: Style/Flavor - Previous: Lot Number - Previous: Manufacturer/Guarantor - Previous Product Address City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Attach a File: Previous Product Image #1 One file only.256 MB limit.Allowed types: gif jpg jpeg png. Attach a File: Previous Product Image #2 One file only.256 MB limit.Allowed types: gif jpg jpeg png. Current Product Information Product Brand Name - Current: Style/Flavor - Current: Lot Number - Current: Manufacturer/Guarantor - Current Product Address City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP/Postal Code Attach a File: Current Product Image #1 One file only.256 MB limit.Allowed types: gif jpg jpeg png. Attach a File: Current Product Image #2 One file only.256 MB limit.Allowed types: gif jpg jpeg png. *Do NOT throw any remaining product away until after an investigation by GDA has been performed* Describe any other details surrounding the complaint CAPTCHA
