2. Length of Power Outage at Your Facility
4. Food Temperature in the Refrigerator
5. Food Temperature in the Freezer
7. Was there flooding?

   1. Yes
   2. No
8. Was the ice machine turned off?

   1. Yes
   2. No
10. Name & Location of Facility
12. Phone Number
13. Name of Caller
15. Date of Call
    Date of Call
16. Time of Call
    Time of Call
18. Note
    Keep a list of food items that have been discarded.
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19. Print Only

* indicates a required field