E-1 

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 
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 Weights 

(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

(Labeled Wt + 13 – 13a)

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

Product Description, Lot Code, Unit Price Money Errors Package Errors 

- +

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 
E-3 

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 

  Moisture Allowance N/A 

14. Nominal Gross Wt 

(Labeled Wt + 13 – 13a) 

Label Wt + 0.020 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 0 .021 lb 

c. Net Wt 1.832 lb 1.202 lb 

d. Package Error 

 (a – 14 = ) -18 -8 

Product Description, Lot Code, Unit Price Money Errors Package Errors 

- + 

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 

Official’s Signature Comments: 

Product found to contain less than the stated net contents

Acknowledgement of Report 
E-4 

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 Package 

Errors (Rc) 

10. Range of Tare Weights 

(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-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 Package 

Errors (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 

  Moisture Allowance

  Vacuum Pack N/A 

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