FGIS 921 Inspection Log

OMB APPROVED NO. 0580-0013
U.S. DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

INSPECTION LOG

NAME OF VESSEL

LOCATION

GRADE TO BE LOADED

QUANTITY

DESTINATION

CERTIFICATION OPTION

NAME OF SHIPPER/AGENT/ACCOUNT
PAGE

LOADING STARTED

OF

SAMPLING METHOD

DATE

TIME

LOADING FINISHED STOWAGE EXAMINATION
DATE

TIME

SHIPPING BINS
SHIP
TYPE OF SAMPLE

DELIVERY SYSTEMS PASSED PRIOR TO
LOADING
AT
BY

ON

LOAD ORDER NUMBER

Date

S/L

TIMES

BINS

STOWAGE Quantity Odor

NAME OF INSPECTOR / CODE NO.

Average
Rounded
GRADE

Form FGIS-921 (07/04)
Edition 03/85 may be used

OMB No. 0580-0013: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0580-0013. The time required to complete this information collection is estimated to average 6.66 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Expires January 2015.

Note: The top information area is the only portion fillable.

U.S. DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

INSPECTION LOG

NAME OF VESSEL

LOCATION

LOADING STARTED

GRADE TO BE LOADED

QUANTITY

DESTINATION

CERTIFICATION OPTION

NAME OF SHIPPER/AGENT/ACCOUNT
PAGE

OF

NAME OF INSPECTOR / CODE NO.

GRADE

FGIS-921 (Reverse)

TIME

LOADING FINISHED STOWAGE EXAMINATION
DATE

SHIP
TYPE OF SAMPLE

DELIVERY SYSTEMS PASSED PRIOR TO
LOADING
AT
ON

General remarks

Notified When Inspector

Sampler

Sublot notes

TIME

SHIPPING BINS

BY

LOAD ORDER NUMBER

S/L

SAMPLING METHOD

DATE

NOTE: This is the FRONT side of the form. To
record a sublot you must fill-out both sides of the
form to record all the information concerning the
sublot.

This worksheet intended to print on legal-sized paper (8 1/2 x 14 inch)

This area (top) is automatically
filled-out when the front is
completed.

NOTE: This is the REVERSE side of the form.
To record a sublot you must fill-out the columns
on both sides of the form to record all the
information concerning the sublot.

FORM FGIS-921, INSPECTION LOG
An inspection log provides a record of sampling, inspection, and significant or unusual events
occurring during the loading or unloading of grain offered for inspection as a shiplot, unit train
lot, lash barge lot, or combined lot. Inspection logs are the source document for preparing
official certificates and any other report used to document the loading of the lot.
Record shiplot, unit train lot, lash barge lot, and combined-lot inspection information on Form
FGIS-921, "Inspection Log," and, if necessary, print additional pages of this sheet for
continuation of the loading. Inspection logs are used to record information obtained from
original inspections, reinspections, or appeal inspections performed on samples drawn during
loading or unloading or on the basis of file samples. Use of an inspection log does not preclude
the use or maintenance of other records (e.g., sample tickets).
The FGIS field office or official agency conducting the inspection shall retain the original copy
of the form. If the inspection is conducted by an official agency, one copy shall be sent to the
supervising field office. If requested, one or more copies shall be given to the applicant or to an
interested person.

Instructions for Completing FGIS-921,
"Inspection Log"
1

Identification of the grain in terms of name, number, or initials of the carrier(s).
Precede the name of a ship with its means of propulsion (M/T, M/V, S/S, etc.).
Barges and other carriers shall be identified by initials and number or name.

2

Name of the pier, elevator, or other specific location where the grain is sampled.
Name of the city and State where the loading or unloading facility is located.

3

Contract grade along with any special grade or contract requirements.

4

Approximate amount of grain loaded or unloaded in terms of pounds, bushels,
short tons, or metric tons.

5

Destination of the shipment.

6

Load Order Number (Field Office or customer’s)

7

Name of the applicant, agent, or account number.

8

Certification option, (e.g., Option 1 or 2).

9

Enter in the type of sampling device (e.g., diverter, probe, pelican, Ellis cup, or
Woodside).

10

Place whether a "Official" or "Official File" sample.

11

Date and military time the elevator (a) begins to preload shipping or surge bin(s),
if any, and (b) begins delivering the grain to the carrier. Enter the date and
military time the elevator (a) finished loading into shipping or surge bin(s), if any,
and (b) finished delivering grain to the carrier.

12

Date, time, and initials of the person(s) who passed the delivery system prior to
loading.

13

(a) the identification of the stowage area(s) examined; (b) whether or not the
stowage area(s) was fit to receive grain; (c) the date, time, and examiner's initials;
and (d) if rejected, the reason(s) why the stowage area was unacceptable.

14

Enter the factor names for the type grain loading and results of any additional
factor analysis (e.g., garlic, ergot, and sprout damage) or other information (e.g.,
belt numbers, file sample numbers, etc.) as needed.

14

Enter the factor names for the type grain loading and results of any additional
factor analysis (e.g., garlic, ergot, and sprout damage) or other information (e.g.,
belt numbers, file sample numbers, etc.) as needed.

15

Grade limit for each factor to be examined.

16

Breakpoint for each factor to be examined and starting value for each factor to be
examined (e.g., "3.0/0.3").

17

Date(s) that each sublot is loaded aboard the carrier or into shipping bin(s)
whichever is earliest.

18

Each sublot number.

19

Military time that each sublot started and finished being loaded aboard the carrier
or into shipping bin(s), enter like this "1103/1145".

20

Identification of the shipping bin(s) that comprises each sublot. (Shipping bin
facilities only.)

21

Stowage area(s) for each sublot. If additional space is needed, use the "Remarks"
section. (See item 36 .)

22

Weight of each sublot in pounds, unless in Canada.

23

Odor of each sublot as OK, SOUR, MUSTY, or COFO.

24

Factor results for each sublot.

25

Cu-Sum for each sublot.

(Reverse side of form)
26

Name(s) of the inspector(s) grading each sublot.

27

Name(s) of the sampler(s) sampling each sublot.

28

Name of the elevator superintendent, applicant for inspection, or representative
notified of each sublot's results.

29

Military time that the person in item 28 was notified.

30

Notes which pertain to this sublot or sample only.

31

General remarks or notes for loading history of vessel. The final stowage
statement for the vessel, grain quality improvement act checks, buyer requests etc.
placed here.

NOTE: If the lot is completed in the available space on file of the FGIS-921, complete
items 32 through 35. Otherwise, complete as many sheets of this form as
necessary.
(Front side of form)
32

Mathematical or weighed average to the hundredth place for each factor.

33

Rounded and adjusted averages, if applicable, for each factor as they will appear
on the official certificate.

34

Name(s) and code number(s) of the inspection personnel who assigned the final
grade.

35

Final grade as it will appear on the official certificate.

CONTACT INFORMATION:
Contact the field office responsible for the geographic area in which the service will be provided.
Details for these locations can be found at:
http://www.gipsa.usda.gov/GIPSA/webapp?area=home&subject=fc&topic=fsp
The signed form should also be mailed to this location.
For further information on the Warehouse Sample-Lot Inspection Service Contract
CONTACT
Wade Berteau
USDA, GIPSA
Field Management Division
Policy and Procedures Branch
1400 Independence Ave. Rm. 2409 N
Washington, DC 20250-3630
Telephone: (202) 720-0252
Fax questions: to (202) 720-7883
Email questions:
wade.s.berteau@usda.gov