Product Recall Destruction Certification Form

Product Recall Destruction Certification Form
Document the destruction of recalled product(s), including the recall details, destruction event, and certification that the items are no longer available for use or resale.
Recall and Product Details
Recall Identifier / Reference Number
Product Name or Description
SKU or Model Number
Lot / Batch Number
Recall Notification Date
MonthDayYear
Date
Destruction Event Details
Destruction Date
MonthDayYear
Date
Destruction Location
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Destruction Method
Other
Quantity Destroyed
Do any residue or remnants remain?
Certification and Sign-off
Certifying Person Name
First NameMiddle NameLast Name
Job Title
Organization / Company Name
Certification Statement
Signature
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