QID Out of Business Screener

Project Code 633

OMB No. 0535-0140 Approval Expires 05/31/2016

OUT OF BUSINESS SCREENER (Telephone Only)

NATIONAL AGRICULTURAL STATISTICS SERVICE

Survey Name OR Census/Survey ID: _____________________________________________________

National Field Office U.S. Department of Agriculture, Rm 5030, South Building 1400 Independence Ave., S.W. Washington, DC 20250-2000 Phone: 1-800-727-9540 Fax: 202-690-2090 Email: nass@nass.usda.gov

FIPS

POID

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SUBTRACT

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The information you provide will be used for statistical purposes only. In accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107–347 and other applicable Federal laws, your responses will be kept confidential and will not be disclosed in identifiable form to anyone other than employees or agents. By law, every NASS employee as well as every agent has taken an oath and is subject to a jail term, a fine, or both if he or she willfully discloses ANY identifiable information about you.  Response is voluntary. 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 number is 0535-0140. The time required to complete this information collection is estimated to average 10 minutes 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. Operator Name:______________________________________________________

(Enumerator Note: For the target on the above POID, fill out the following information.)

1. I would like to ask you a few questions about your involvement in agriculture.
a. Will you grow any field crops, hay or specially crops such as fruits, vegetables or floriculture?
	Yes [Check all that apply]
	No [Continue]
			Field Crops		Vegetables
			Hay		Mushrooms
			Fruit/Nut Trees		Maple Syrup
			Berries		Other agricultural land use
			Floriculture/Nursery/Greenhouse		Specify:_________________________
			Bison/LLamas/Alpacas
b. Do you own or raise any: livestock or poultry?
	Yes [Check all that apply]
	No [Continue]
		Beef Cattle			Chickens/Broilers			Ostriches
		Dairy Cattle			Turkeys			Bee Colonies
		Hogs			Equine			Other Livestock Specify:______________
		Sheep			Mink			Other Poultry Specify:________________
		Goats			Aquaculture			Equine/Horses/Mules
[Enumerator: If any commodity in 1a. or 1b. is checked, Go to Item 5. If nothing is checked continue to 1c..]

c. Do you have facilities for storing whole grains, pulse crops, or oilseeds?
Yes [Go to Item 5]
No [Continue]
d. Do you have own or operate any CRP/WRP, pasture, woodland, idle land?
Yes [Go to Item 5]
No [Continue)

2. Do you plan to operate a farm or ranch in the future?
Yes [Continue]
No[Continue]
Don’t Know [Continue]
3. What is the reason the operator is not currently farming or ranching? Check reason below.	What is the name and address of the new operator that has taken over the day-to-day decisions on this operation?
The operator is deceased?	Operation Name:______________________________________
The operator is retired?	Operator Name:_________________________________________
The operation was out of business or sold?	Address:____________________________________________
The operator is a landlord? (rents entire farm out to someone else)	City:_____________ State_________ Zip:________________
The operator moved out of state? [Specify:__________________]	Phone:_________________________________
The operation was on leased land? (Operator gave up lease) [Go to Item 4]
The operation was never a farm. [Go to Item 5]
Other Reason? [Explain:__________________] [Go to Item 4]
4. When did this change occur? . . . . . . . . . . . . . . . . . . . . . . . . . . .
		MM	YYYY
5. This Completes the Survey. Thank you for your help.
Respondent Name: _____________________ Phone ( )__________________				Date ___/______/__________
Please leave any notes that might help the List Frame Section.

Enumerator Name:	______________________________________	Enum ID:
List Frame Action Taken: ______________________________________