Form FSR 179 USDA FSIS FSR 179 USDA FSIS FSR 179 USDA FSIS

USDA Food Safety and Inspection Service

 Does your employment involve food processing or food production?  (mark one)  ____  Yes    ____  No

If yes, The following best describes your affiliation:  (mark all that apply)

____  Red meat slaughter                               ____  Poultry slaughter                     ____  Egg product   

____  Red meat processing                             ____  Poultry processing                  ____  Animal production

____  Ready-to-Eat processed products         ____  Raw processed products ____ Other _________________

If you are affiliated with a meat, poultry, or egg products firm, what is the size of the plant? (mark one):

___ Very small (1-9 employees)    ___ Small (10-499 employees)   ____ Large (500 or more employees)

In order for FSIS to focus its outreach efforts, please indicate your ethnic background:  (mark all that apply)

____ African-American/Black                                      ____ Hispanic/Latino

____ American Indian/Alaska Native                          ____  White/Caucasian

____ Asian                                                                 _____ Pacific Islander

____ Other (please specify): 

 

What is the primary language used by your employees, particularly on the processing floor?  (mark one)

____  English    ____  Spanish    ____  Other (please specify):  _____________________________________

 

Where is your plant located?   Please indicate city and state.  __________________________________