Appendix E. Model Inspection Report Forms 

Report Form Page

Random Inspection Report E-2 

Random Package Inspection Report - Example E-3 

Standard Package Inspection Report E-4 

Standard Inspection Report - Example E-5 

E-1 
Date 

Random Package Report

Sampling Plan: A  B  Report Number: 

Location (name, address) Product/Brand Identity

Lot Codes 

Manufacturer: Container Description:

1. Labeled Quantityenter weight for each 

package in column 1 

below.

2. Unit of Measure 3. MAV – look up the MAV for each package with a 

minus error, convert it to dimensionless units 

and enter this value in Column 4 below. 

5. Inspection Lot Size 6. Sample Size (n) 

7. Initial Tare Sample

Size 

 

8. No. of MAVs Allowed 9. Range of Package 

Errors (Rc) 

10. Range of Tare Wts. (Rt) 11. Rc/Rt (9)10 = ) 12. Total No. of Tare 

Samples: 

13. Avg. Tare Wt :  Used Dry Tare  Wet Tare  Unused Dry Tare 13a.  Tare Correction

  Moisture Allowance 

14. Nominal Gross Wt.

Pkg 1 Pkg 2 Pkg 3 Pkg 4 Pkg 5 Pkg 6 Pkg 7 Pkg 8 Pkg 9 Pkg 10 

a. Gross Wt.

b. Tare Wt. 

c. Net Wt.

d. Package Error

Money Errors Package Errors Product Description, Lot Code, Unit Price - + 1. Labeled Net Weight - + 4. MAV 

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

 Totals

15. Total Error 16. No. of unreasonable minus errors

(compare each package error with the

MAV in Col 4): 

17. Is 16 greater than 8?

 Yes, Lot Fails  No, go to 18 

18. Avg. error in dimensionless 

units. (15 ) 6 =) 

19. Avg. error in 

labeled units (18 x 2 

=) 

20. Is 18 Zero or Plus?

 Yes, lot passes, go to 25 

 No, go to 21 

21. Compute Sample 

Standard Deviation: 

22. Sample Correction Factor: 23. Compute Sample Error Limit (21 x 22 =): 

24. Disregarding the signs, is 18 larger than 23: 

 Yes, Lot Fails, go to 25  No, Lot Passes, go to 25 

25. Disposition of Inspection Lot: 

 Approved  Rejected 

Comments:

Official’s Signature 

Acknowledgement of Report 

E-2 
Date 

September 16, 1999 

Random Package Report - Example Form

Sampling Plan: A  B  

Report Number: 

 17

Product/Brand Identity: 

 Ground Chuck 

Location (name, address)

L&O Market 

MacCorkle Ave 

Charleston, WV 25177 Lot Codes 

 1, 19, 99 

Manufacturer: 

Meat Department – L&O Market

Container Description: 

2S Tray with soaker and 

plastic wrap 

1. Labeled Quantityenter weight for each 

package in the column 1 

below. 

2. Unit of Measure 

 

 0.001 lb 

3. MAV – look up the MAV for each package with a 

minus error, convert it to dimensionless units 

and enter this value in Column 4 below. 

5. Inspection Lot 

Size 

 23

 6. Sample Size (n) 

 12

7. Initial Tare Sample 

Size 

 2 

8. No. of MAVs Allowed 

 

 0

9. Range of Package 

Errors (Rc)

 10

10. Range of Tare Weights(Rt) 

 1

11. Rc/Rt (9)10 = )

 10

12. Total No. of Tare

Samples: 

 2 

13. Avg. Tare Wt :  Used Dry Tare  Wet Tare  Unused Dry Tare

 

 0.0205 lb

13a.  Tare Correction 

 N/A 

 Moisture Allowance 

14. Nominal Gross Wt

Label Wt + .020 lb

Pkg 1 Pkg 2 Pkg 3 Pkg 4 Pkg 5 Pkg 6 Pkg 7 Pkg 8 Pkg 9 Pkg 10 

a. Gross Wt. 1.852 lb 1.223 lb 

b. Tare Wt. 0 .020 lb .021 lb 

c. Net Wt. 1.832 lb 1.202 lb 

d. Package Error 

(a – 14 = ) -18 -8

Money Errors 

Package Errors Product Description, Lot Code, Unit Price - + 1. Labeled Net Weight - +

4. MAV 

1. Ground Chuck - 1, 19, 99 - $1.79 per lb 1.85 lb 18

2. 1.21 lb 7

3. 1.56 lb 8

4. 1.98 lb 14

5. $0.04 1.07 lb 23 44 

6. 1.55 lb 16

7. 1.02 lb 2

8. $0.04 1.44 lb 25 56 

9. 1.33 lb 16

10. 2.03 lb 20 70 

11. 1.73 lb 14

12. 1.16 lb 11

13. 

14. 

15. 

16. 

17. 

18. 

19. 

20. 

21. 

22. 

23. 

24. 

 Totals 174 

15. Total Error 

 - 174 

16. No. of unreasonable minus errors

(compare each package error

 with 4) 

 0

17. Is 16 greater than 8?

 Yes, Lot Fails  No, go to 18 

18. Avg. error in dimensionless 

units. (15 ) 6 =) 

 - 14.5

19. Avg. error in 

labeled units (18 x 2 

=)

 - 0.014 lb 

20. Is 18 = Zero or Plus? 

 Yes, lot passes, go to 25 

 No, go to 21 

21. Compute Sample 

Standard Deviation: 

 

 6.721 

22. Sample Correction Factor: 

 

 0.635 

23. Compute Sample Error Limit (21 x 22 =): 

 4.267 

24. Disregarding the signs, is 18 larger than 23: 

 Yes, Lot Fails, go to 25  No, Lot Passes, go to 25

25. Disposition of Inspection Lot: 

 Approved  Rejected 

Comments: Product found to contain less than the stated net contents Official’s Signature 

Acknowledgement of Report 

E-3 
Date Standard Package Report 

Sampling Plan: A  B 

Report Number 

Location (name, address) Product/Brand Identity

Lot Codes 

Manufacturer Container Description

1. Labeled Quantity 2. Unit of Measure 3. MAV 4. MAV (dimensionless units) (3 ) 2 =) 5. Inspection Lot 

Size 

6. Sample Size (n)

7. Initial Tare Sample

Size 

 

8. No. of MAVs Allowed 9. Range of Net Wts.

(Rc) 

10. Range of Tare Wts. (Rt) 11. Rc/Rt (9)10 = ) 12. Total No. of Tare

Samples: 

13. Avg. Tare Wt :  Used Dry Tare Wet Tare  Unused Dry Tare 13a. Tare Correction 

 Moisture Allowance  Vacuum Pack 

14. Nominal Gross Wt.

(1 + 13 – 13 a =)

Pkg 1 Pkg 2 Pkg 3 Pkg 4 Pkg 5 Pkg 6 Pkg 7 Pkg 8 Pkg 9 Pkg 

10 

a. Gross Wt. 

b. Tare Wt. 

c. Net Wt. 

- +  + - + - +

1. 13. 25. 37.

2. 14. 26. 38.

3. 15. 27. 39.

4. 16. 28. 40.

5. 17. 29. 41.

6. 18. 30. 42.

7. 19. 31. 43.

8. 20. 32. 44.

9. 21. 33. 45.

10. 22. 34. 46.

11. 23. 35. 47.

12. 24. 36. 48.

Total Total Total Total Total Total Total Total

15. Total Error 16. No. of unreasonable minus errors (compare each 

package error with 4): 

17. Is 16 greater than 8?

 Yes, lot fails 

 No, go to 18 

18. Avg. error in 

dimensionless units.

(15 ) 6 =) 

19. Avg. error in labeled 

units (18 x 2 =)

20. Is 18 = Zero or Plus?

 

 Yes, lot passes, go to 25 

 No, go to 21 

21. Compute Sample 

Standard Deviation: 

22. Sample Correction Factor: 23. Compute Sample Error Limit (21 x 22 =): 

24. Disregarding the signs, is 18 larger than 23: 

 Yes, lot fails, go to 25  No, lot passes, go to 25

25. Disposition of Inspection Lot: 

 Approved  Rejected 

Comments: Official’s Signature 

Acknowledgement of Report 

E-4 
E-5 

Date 

January 20, 1999 Standard Package Report - Sample Form Sampling Plan: A  B  Report Number  16 

Product/Brand Identity: 

Community Group Cookies (Thin Mints) 

Location (name, address) 

Volunteer Market 

18765 Alcoa Highway 

Knoxville, Tennessee 

37920 Lot Codes 

 April 1998 A&B 

Manufacturer: 

ABC Cookies Inc 

1069 Capitol Avenue 

Nashville, Tennessee 37204 

Container Description 

Cardboard Box / Plastic Liner 

1. Labeled 

Quantity 

453 g (1 lb) 

2. Unit of Measure 

 0.001 lb 

3. MAV 

 0 .044 lb 

4. MAV (dimensionless units) (3 ) 2 =) 

 44

5. 

Inspection 

Lot Size 

172 

6. Sample Size (n) 

 12 

7. Initial Tare 

Sample Size 

 2 

 

8. No. of MAVs 

Allowed 

 0 

9. Range of Net Wts. (Rc) 

 24 

10. Range of Tare 

Weights (Rt) 

 2 

11. Rc/Rt 

(9)10 = ) 

 12 

12. Total No. of Tare Samples: 

 2 

13. Avg. Tare Wt :  Used Dry Tare  Wet Tare  Unused Dry Tare 

 0 .014 lb

13a. Tare Correction 

 N/A 

 Moisture Allowance  Vacuum 

Pack 

14. Nominal Gross Wt. 

(1 + 13 – 13 a =) 

 1.014 lb 

Pkg 1 Pkg 2 Pkg 3 Pkg 4 Pkg 5 Pkg 6 Pkg 7 Pkg 8 Pkg 9 Pkg 10 

a. Gross Wt. 1.052 lb 1.026 lb 

b. Tare Wt. 0.015 lb .013 lb 

c. Net Wt. 1.037 lb 1.013 lb 

- + - + - + - + 

1. 38 13. 25. 37. 

2. 12 14. 26. 38. 

3. 8 15. 27. 39. 

4. 4 16. 28. 40. 

5. 3 17. 29. 41. 

6. 2 18. 30. 42. 

7. 12 19. 31. 43. 

8. 3 20. 32. 44. 

9. 4 21. 33. 45. 

10. 1 22. 34. 46. 

11. 0 23. 35. 47. 

12. 6 24. 36. 48. 

Total 9 Total 84 Total Total Total Total Total Total 

15. Total Error 

 

 + 75 

16. No. of unreasonable minus errors (compare each 

package error with 4): 

 0 

17. Is 16 greater than 8? 

 Yes, lot fails 

 No, go to 18 

18. Avg. error in 

dimensionless units. 

(15 ) 6 =) +6.25 

19. Avg. error in labeled 

units (18 x 2 =) 

 + 0.006 lb 

20. Is 18 = Zero or Plus? 

 Yes, lot passes, go to 25 

 No, go to 21 

21. Compute Sample 

Standard Deviation: 

22. Sample Correction Factor: 23. Compute Sample Error Limit (21 x 22 =): 

24. Disregarding the signs, is 18 larger than 23: 

 Yes, lot fails, go to 25  No, lot passes 

25. Disposition of Inspection Lot: 

 Approved  Rejected 

Comments: Official’s Signature 

 Lot Passes

Acknowledgement of Report