11B (LS elec. ver. Livestock Customer Survey

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AMS-11 B (06-05)

Form Approved.

Livestock Customer Survey

- OMB No. 0561-0182

CanceL

Product Name (Choose One)

Contract Number:

Date Packed:

I
US Inspected Seal No.:

Product Served In:

r School

r Other

City:

State:

School/Institute Name:

J
Respondent's Job Title:

Phone Number:

E-Mail Address: (Required)

Acceptability of Product (Choose One from Each Category)
Flavor:

r
r

Unsatisfactory

Needs Improving

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r
r

Good
Excellent

Texture:

r

r

r
r
r

Unsatisfactory
Needs Improving
Adequate

Good
Excellent

Appearance:

r

r
r
r
r

Unsatisfactory
Needs Improving
Adequate

Good
Excellent

Overall Satisfaction:

r

Unsatisfactory

("

Needs Improving

r Adequate

r
r

Good
Excellent

Plate Waste:

r
r

r

Very High
High

Normal

rLow

r VeryLow

What about this product did you or the students like?

What about this product did you or the students not like?

Howcould we Improve the product or Its packaging?

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Cancel

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 collection is 0581-0182. The
time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing
instructions,searching existingdata sources, gatheringand maintainingthe data needed, and completingand reviewingthe collectionof
information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic
information,politicalbeliefs,reprisal, or because allor part ofan individual'sincomeis derivedfromany publicassistance program (Not all
prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information
(Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of
discrimination, write to USDA, Director,Officeof Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call
(800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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