QID Applications Consent Form - VCUS

Project 136

QID 035219

OMB No. 0535-0218

2013 Vegetable Chemical Use Survey
Chemical Applications Consent Form

VERSION

POID

SUBTRACT

01

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Approval Expires XX/XX/XXXX

NATIONAL
AGRICULTURAL
STATISTICS
SERVICE
U.S Department of Agriculture
Rm. 5030, South Building
1400 Independence Avenue, S.W.
Washington, D.C. 20250-2000
1-800-727-9540
Fax: 202-690-2090
Email: [email protected]

The National Agricultural Statistics Service (NASS) of the U.S. Department of Agriculture is conducting a
survey of the Vegetable Chemical Usage for the 2013 crop year. The survey will be conducted from
October, 2013 through January, 2014.
By signing this Consent Form, the Owner agrees to allow the vegetable caretaking company listed below to
provide the necessary information for the completion of the Vegetable Chemical Use Survey for the
selected operation to the National Agricultural Statistics Service. Authority for collection of information on
the Vegetable Chemical Use Survey is Title 7, Section 2204 of the U.S. Code. Under Title 7 of the U.S.
Code and CIPSEA (Public Law 107-347), facts about your operation are kept confidential and used only for
statistical purposes. Response is voluntary. Results of the survey, showing State and National level results
for the selected vegetables will be available at the end of July, 2014.

Operation Name:

_____________________________________________________________________

Owner Name:

_____________________________________________________________________

Owner Address:

_____________________________________________________________________

_____________________________________________________________________

Owner Signature:

_____________________________________________________________________

Date:

_________________________________

Vegetable Caretaking
Company Name:

_____________________________________________________________________

Vegetable Caretaking
Company Address:

_____________________________________________________________________
_____________________________________________________________________

Phone Number:
NASDA Field Enumerator:

_________________________________

____________________________________________________

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 0535-0218. The time required to complete this information collection
is estimated to average 5 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.