Rapid Alert System for Food and Feed

Regulation (EC) No 178/2002 – Art. 50 Original notification

GENERAL INFORMATION 1 Contact point reference n°: 2 Notification type: 3 Notification basis: 4 Notification classification: 5 Notifying country: 6 Date of notification: 7 Linked RASFF notification: 8 Product relation to the product notified in linked other/more info: notification: 9 Information source: 10 Countries flagged for follow-up: 11 Countries flagged for attention: 12 INFOSAN (to be) informed: by notifying country reason: by Commission services no RISK 13 Serious risk: yes motivate:

no 14 Impact on: human health 15 Number of persons affected: 16 Type of illness/symptoms: 17 Hazards observed:

PRODUCT: 18 Product: 19 Product category: a-l m-z other: 20 Product name(s) (on label): 21 Product CN-code: 22 Product Brand(s) / trade description name(s): 23 Product aspect (e.g. packaging): 24 Barcode n°:

Original notification form: version 3.3 Page 1 of 5 25 Other labelling: 26 Unit weight/vol.: units 27 Temperature:

SAMPLING: 28 Sampling dates: / / / / / 29 Sampling info: 30 Sampling place: other/name: 31 Analysis Laboratory: Name: Street: Locality: Postal: Country: 32 Sample treatment / matrix: 33 Analytical method(s): 34 Number of samples: 35 Counter analysis: : / / / / / units 36 Hazards identified: 37 Analytical results: / / / / / units 38 Outcome of analysis:

LEGISLATION 39 EU legislation: 40 National legislation: 41 Other standard: 42 Max. permitted level: units

PRODUCT TRACEABILITY: 43 Distribution status:

44 Consignment(s) / lot / / / number(s): 45 Country of origin: 46 Public Number(s): / / / health 47 certificate Date(s): / / / 48 CVED/CED number(s): / / / 49 Other document: type: number: 50 Durability Use-by date: / / / dates 51 Best before date: / / / 52 Sell-by date: / / / 53 Descrip- Number of units: / / /

Original notification form: version 3.3 Page 2 of 5 54 tion of Total net units / units / units / units the lot weight/volume:

55 operator Name: 0 type 56 Street + nr: country:

57 Postal + city: approval / reg. number: 58 Distribution to: country list (region) 59 operator Name: type 60 Street + nr: country:

73 Postal + city: approval / reg. number: 74 Distribution to: country list (region)

MEASURES: 75 Voluntary measures: Information by: internet: (hyperlink) Taken by: paper news media Contact person: TV Additional info: radio information at retail point informing clients

76 Compulsory measures: Information by: internet: (hyperlink) Taken by: paper news media reinforced checking TV

Original notification form: version 3.3 Page 3 of 5 Contact person: radio Additional info: information at retail point informing clients 77 Date of entry into force: 78 Duration:

BORDER CONTROL: 79 Border post: 80 Point of control: 81 Reason for inspection: random targeted detail: 82 Point of departure: 83 Country of dispatch: 84 Country of destination: 85 Consignee Name: 86 Address: 87 Transport: other/more info: 88 Container n°(s)/seal n°(s): / / / /

OTHER INFORMATION: 89 Organisation/ministry: 90 Contact person: 91 Additional information:

92 Attached documents: health certificate (compressed format) CVED/CED phytosanitary certificate Can be made public warning / press release available to third parties?1 analytical report

bills / delivery documents

pictures

risk assessment

other: 93 What information will be only product other: made public?2 RASFF identification portal

1 Documents should not be made available to third parties unless the corresponding box is checked in this column. 2 according to article 52(1) of Regulation (EC) No 178/2002

Original notification form: version 3.3 Page 4 of 5 94 Reason: numbers underlined: information that is required in all cases (should always be filled) numbers highlighted: information that may be required in some cased (depending on the context)

Original notification form: version 3.3 Page 5 of 5