Form QID 150028 QID 150028 Agricultural Labor Survey - October, 2015

AGRICULTURAL LABOR SURVEY - October 2015
			OMB No. 0535-0109 Approval Expires: 3/31/2018 Project Code: 956 QID: 150028 SMetaKey: 3275
				United States Department of Agriculture
				NATIONAL AGRICULTURAL STATISTICS SERVICE

						USDA/NASS National Operations Division 9700 Page Avenue, Suite 400 St. Louis, MO 63132-1547 Phone: 1-888-424-7828 Fax: 1-855-415-3687 E-mail: [email protected]

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 employee and 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 or your operation.  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 control number is 0535-0109. The time required to complete this information collection is estimated to average 30 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.

Attempted Contacts

Date

Time

Notes

State

POID

Tract

Subtr.

__ __

__ __ __ __ __ __ __ __ __

__ __

__ __

1. [Verify name and mailing address of this operation. Make any corrections necessary (including the correct operation name) on the label and continue.]

[Check if name label verified]

2. Since June 1, 2015, have you or will you (name on label)--

a. grow any crops or cut hay? [Include grains, row crops, oilseeds, fruits, nuts, vegetables (including strawberries and melon crops), nursery and greenhouse, Christmas trees, and other specialty crops.]
	1 Yes - [Go to item 3.] 3 No - [Continue.]
b. own or raise any livestock or poultry? [Include livestock and poultry owned, and any being raised under contract for someone else.]
	1 Yes - [Go to item 3.] 3 No - [Continue.]
c. sell any agricultural products?
	1 Yes - [Go to item 3.] 3 No - [Continue.]
d. receive government agricultural payments? [Exclude government payments received as a landlord.]
	1 Yes - [Go to item 3.] 3 No - [Continue.]
e. have more than 19 acres of idle cropland or more than 99 acres of pastureland?
		1 Yes - [Go to item 3.] 3 No - [Go to Section 5, page 11, item 1.]

			OFFICE USE
3. Are the day-to-day decisions for this operation made by one individual, a hired manager, or partners? [Check one]			R. UNIT
			9921
1 One individual – [Go to Section 1, page 4, item 1.] 8 A hired manager – [Go to Section 1, page 4, item 1.] 2 Partners – How many partners make the day-to-day decisions?			SUB.
			9941
	Number		JUNE 1
[Enter number of partners, including operator, and then continue.]. . . . . .. . . . . . . . . .	     		9930

4. Please identify the other person(s) in this partnership, then go to Section 1, page 4. (Verify partners’ names and make necessary corrections if names have already been entered.)
Name: __________________________________________				Name: __________________________________________
Address: ________________________________________				Address: ________________________________________
City: ____________________ State: ______ ZIP: _______				City: ____________________ State: ______ ZIP: _______
Phone: (______ ) - ______________________				Phone: (_______) - ____________________
Did this partner also operate land individually on June 1, 2015?				Did this partner also operate land individually on June 1, 2015?
Yes No				Yes No
Name: __________________________________________				Name: __________________________________________
Address: ________________________________________				Address: ________________________________________
City: ____________________ State: ______ ZIP: _______				City: ____________________ State: ______ ZIP: _______
Phone: (______) - _____________________				Phone: (_______) - ____________________
Did this partner also operate land individually on June 1, 2015?				Did this partner also operate land individually on June 1, 2015?
Yes No				Yes No

For Office Use Only		For Office Use Only		For Office Use Only		For Office Use Only
Stratum		Stratum		Stratum		Stratum
9922		9923		9927		9928
Ind. Op.		Ind. Op.		Ind. Op.		Ind. Op.
9924		9924		9924		9924

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Or

Space for Notes and Comments

		October 2015
		S	M	T	W	Th	F	S
						1	2	3
		4	5	6	7	8	9	10
		11	12	13	14	15	16	17
		18	19	20	21	22	23	24
		25	26	27	28	29	30	31

Section 1 - PAID WORKERS for OCTOBER

1. Did this operation have anyone on the payroll to do agricultural work the week of October 12th through the 18th?
[Only report workers directly hired and paid by the farm operation. Include part-time workers, paid family members, and hired managers. Include all hired workers regardless of method of pay. Exclude contract and custom workers, retail workers and “value-added” workers (exclude retail sales workers, for example)].	CODE
	599 10
1 Yes - [Enter 1 and continue.] 2 Don't Know - [Enter 2, then go to Section 2.] 3 No - [Enter 3 then go to Section 2.]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	600

2. For the paid workers, record the number of workers, hours worked, and the gross wages paid the week of October 12^th through the 18^th.
**Record each worker only once.
**Separate the workers by the main type of work they were hired to do based on the groups outlined on page 5:

Work Hired to Do	Worker Code (shown on page 5)		Number of Paid Workers	Total Hours Worked		Total Gross Wages That Week (Dollars)
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
3. TOTAL PAID WORKERS		660

4. In 2015, how many of these TOTAL PAID WORKERS will be paid by this operation----		NUMBER OF WORKERS
a. for 150 days or more of work?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		700
b. for 149 days or less of work?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		701
Sum MUST equal TOTAL PAID WORKERS, item 3 above. . . . . . . . . . . . . . . . . . . . . . . . . . . . .	TOTAL	702

Office Use – Completion Code – Usability

1 – Incomplete, Has Labor 2 – Incomplete, Unknown 3 – No Labor

698

Worker codes for Sections 1 and 2
Code	Work Hired to Do
FIELD WORKERS
11	Agricultural Equipment Operators - Crop, Nursery and Greenhouse: Drive and control farm equipment to till soil and to plant, cultivate, and harvest crops.
12	Farmworkers - Crop, Nursery and Greenhouse: Manually plant, cultivate, and harvest vegetables, fruits, nuts, horticultural specialties, field crops, Christmas trees and short rotation woody crops. Use hand tools, such as shovels, trowels, hoes, tampers, pruning hooks, shears, and knives. Duties may include tilling soil and applying fertilizers; transplanting, weeding, thinning, or pruning crops; applying pesticides; or cleaning, grading, sorting, packing, and loading harvested products. May construct trellises, repair fences and farm buildings, or participate in irrigation activities.
13	Graders And Sorters - Crop, Nursery and Greenhouse Products: Grade, sort, or classify agricultural crops by size, weight, color or condition.
14	Hand Packers And Packagers - Crop, Nursery and Greenhouse Products: Pack or package by hand a wide variety of products and materials.
15	All Other Field Workers: All agricultural workers working with crops, nursery or greenhouse products not included in codes 11-14.
LIVESTOCK WORKERS
21	Farmworkers - Farm, Ranch, and Aquacultural Animals: Attend to live farm, ranch, or aquacultural animals that may include cattle, sheep, swine, goats, horses and other equines, poultry, finfish, shellfish, and bees. Attend to animals produced for animal products, such as meat, fur, skins, feathers, eggs, milk, and honey. Duties may include feeding, watering, herding, grazing, castrating, branding, de-beaking, weighing, catching, and loading animals. May maintain records on animals; examine animals to detect diseases and injuries; assist in birth deliveries; and administer medications, vaccinations, or insecticides as appropriate. May clean and maintain animal housing areas. Includes workers who drive and control equipment to accomplish the tasks described.
22	Graders And Sorters - Farm, Ranch, and Aquacultural Animal Products: Grade, sort, or classify unprocessed food and other agricultural products by size, weight, color, or condition.
23	Hand Packers And Packagers - Farm, Ranch and Aquacultural Animal Products: Pack or package by hand a wide variety of products and materials.
24	All Other Livestock Workers: All agricultural workers working with farm, ranch and aquacultural animals or products not included in codes 21 – 23.
SUPERVISORS
31	Farmers, Ranchers and Other Agricultural Managers: Plan, direct, or coordinate the management or operation of farms, ranches, greenhouses, aquacultural operations, nurseries, tree farms, or other agricultural establishments.
32	First-Line Supervisors of Farm Workers: Directly supervise and coordinate the activities of agricultural, aquacultural, and related workers.
OTHER WORKERS
41	Agricultural Inspectors: Inspect agricultural commodities, processing equipment and facilities, and aquacultural operations, to ensure compliance with regulations and laws governing health, quality, and safety.
42	Animal Breeders: Select and breed animals according to their genealogy, characteristics, and offspring.
43	Pesticide Handlers and Sprayers: Mix or apply pesticides, herbicides, fungicides, or insecticides through sprays, dusts, vapors, soil incorporation, or chemical application to all crops including nursery and greenhouse products and facilities, and livestock, and livestock facilities. Usually requires specific training and state or federal certification. Excludes pilots who dust or spray crops from aircraft.
44	Any Other Worker Not Listed Above: Including, but not limited to, mechanics, shop workers, truck drivers, accountants, bookkeepers, office workers. Excluding contract & custom workers, retail workers, and “value-added” workers.

	July 2015
	S	M	T	W	Th	F	S
				1	2	3	4
	5	6	7	8	9	10	11
	12	13	14	15	16	17	18
	19	20	21	22	23	24	25
	26	27	28	29	30	31

Section 2 - PAID WORKERS for JULY

1. Did this operation have anyone on the payroll to do agricultural work the week of July 6th through the 12th?
[Only report workers directly hired and paid by the farm operation. Include part-time workers, paid family members, and hired managers. Include all hired workers regardless of method of pay. Exclude contract and custom workers, retail workers and “value-added” workers (exclude retail sales workers, for example)].	CODE
	599 7
1 Yes - [Enter code 1, and continue.] 2 Don't Know - [Enter code 2, then go to Section 3.] 3 No - [Enter code 3 then go to Section 3.]	600

2. For the paid workers, record the number of workers, hours worked, and the gross wages paid the week of July 6^th through the 12^th.
**Record each worker only once.
**Separate the workers by the main type of work they were hired to do based on the groups outlined on page 7:

Work Hired to Do	Worker Code (shown on page 7)		Number of Paid Workers	Total Hours Worked		Total Gross Wages That Week (Dollars)
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
	611		612	613		614
3. TOTAL PAID WORKERS		660

4. In 2015, how many of these TOTAL PAID WORKERS will be paid by this operation----		NUMBER OF WORKERS
a. for 150 days or more of work?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		700
b. for 149 days or less of work?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		701
Sum MUST equal TOTAL PAID WORKERS, item 3 above. . . . . . . . . . . . . . . . . . . . . .	TOTAL	702

Office Use – Completion Code – Usability

1 – Incomplete, Has Labor 2 – Incomplete, Unknown 3 – No Labor

698

Worker codes for Sections 1 and 2
Code	Work Hired to Do
FIELD WORKERS
11	Agricultural Equipment Operators - Crop, Nursery and Greenhouse: Drive and control farm equipment to till soil and to plant, cultivate, and harvest crops.
12	Farmworkers - Crop, Nursery and Greenhouse: Manually plant, cultivate, and harvest vegetables, fruits, nuts, horticultural specialties, field crops, Christmas trees and short rotation woody crops. Use hand tools, such as shovels, trowels, hoes, tampers, pruning hooks, shears, and knives. Duties may include tilling soil and applying fertilizers; transplanting, weeding, thinning, or pruning crops; applying pesticides; or cleaning, grading, sorting, packing, and loading harvested products. May construct trellises, repair fences and farm buildings, or participate in irrigation activities.
13	Graders And Sorters - Crop, Nursery and Greenhouse Products: Grade, sort, or classify agricultural crops by size, weight, color or condition.
14	Hand Packers And Packagers - Crop, Nursery and Greenhouse Products: Pack or package by hand a wide variety of products and materials.
15	All Other Field Workers: All agricultural workers working with crops, nursery or greenhouse products not included in codes 11-14.
LIVESTOCK WORKERS
21	Farmworkers - Farm, Ranch, and Aquacultural Animals: Attend to live farm, ranch, or aquacultural animals that may include cattle, sheep, swine, goats, horses and other equines, poultry, finfish, shellfish, and bees. Attend to animals produced for animal products, such as meat, fur, skins, feathers, eggs, milk, and honey. Duties may include feeding, watering, herding, grazing, castrating, branding, de-beaking, weighing, catching, and loading animals. May maintain records on animals; examine animals to detect diseases and injuries; assist in birth deliveries; and administer medications, vaccinations, or insecticides as appropriate. May clean and maintain animal housing areas. Includes workers who drive and control equipment to accomplish the tasks described.
22	Graders And Sorters - Farm, Ranch, and Aquacultural Animal Products: Grade, sort, or classify unprocessed food and other agricultural products by size, weight, color, or condition.
23	Hand Packers And Packagers - Farm, Ranch and Aquacultural Animal Products: Pack or package by hand a wide variety of products and materials.
24	All Other Livestock Workers: All agricultural workers working with farm, ranch and aquacultural animals or products not included in codes 21 – 23.
SUPERVISORS
31	Farmers, Ranchers and Other Agricultural Managers: Plan, direct, or coordinate the management or operation of farms, ranches, greenhouses, aquacultural operations, nurseries, tree farms, or other agricultural establishments.
32	First-Line Supervisors of Farm Workers: Directly supervise and coordinate the activities of agricultural, aquacultural, and related workers.
OTHER WORKERS
41	Agricultural Inspectors: Inspect agricultural commodities, processing equipment and facilities, and aquacultural operations, to ensure compliance with regulations and laws governing health, quality, and safety.
42	Animal Breeders: Select and breed animals according to their genealogy, characteristics, and offspring.
43	Pesticide Handlers and Sprayers: Mix or apply pesticides, herbicides, fungicides, or insecticides through sprays, dusts, vapors, soil incorporation, or chemical application to all crops including nursery and greenhouse products and facilities, and livestock, and livestock facilities. Usually requires specific training and state or federal certification. Excludes pilots who dust or spray crops from aircraft.
44	Any Other Worker Not Listed Above: Including, but not limited to, mechanics, shop workers, truck drivers, accountants, bookkeepers, office workers. Excluding contract & custom workers, retail workers, and “value-added” workers.

Section 3 - VALUE of SALES

1. Please classify this operation in terms of total gross value of sales [Be sure sales represent only 2014 and earlier years’ production.]

Considering:

Sales of all crops, livestock, poultry, and livestock products (milk, eggs, etc.) sold in 2014. The value of product removed for all crops, livestock, and poultry produced under contract in 2014. Sales of all miscellaneous agricultural products in 2014. All government agricultural payments received in 2014. Landlord’s share of government payments and crops sold in 2014.

a. What code represents the total gross value of sales, including government agricultural payments?

Total Value					GVS Code
‘None’ during 2014. . . . . . . . . . . .					99
$ $ $ $ $ $ $ $ $ $ $ $	1 --- 1,000 --- 2,500 --- 5,000 --- 10,000 --- 25,000 --- 50,000 --- 100,000 --- 250,000 --- 500,000 --- 1,000,000 --- 2,500,000 ---	$ $ $ $ $ $ $ $ $ $	999 2,499 4,999 9,999 24,999 49,999 99,999 249,999 499,999 999,999 2,499,999 4,999,999	…. …. …. …. …. …. …. …. …. …. …. ….	1 2 3 4 5 6 7 8 9 10 11 12			GVS Code
								550
$	5,000,000 and over ………….				13
b. Does the GVS (gross value of sales) Code in Code Box 550 equal ‘1’ or ‘99’? Yes - [Continue.] No - [Go to page 9, item 2.]
c. Record all 2015 crops, land uses, and livestock or poultry now on the total acres operated, then go to page 9, item 2.

Land Use	ACRES	Field Crops Intended For Harvest	ACRES	Other Crops		ACRES
CRP/WRP . . . . . . . . . . . . . . . . . .	     	__________________	     	Cut Christmas Trees		     
Idle Cropland . . . . . . . . . . . . . . . .	     	__________________	     	__________________		     
Summer Fallow	     	__________________	     	__________________		     
____________________	     	__________________	     	__________________		     
				Livestock		NUMBER
Government Payments	WHOLE DOLLARS	Fruits/Nuts	ACRES	Cattle – Dairy . . . . . . .		     
CRP/WRP Payments . . . . . . . . .	     	__________________	     	Cattle – Other . . . . . . .		     
Other Gov’t Payments . . . . . . . . .	     	__________________	     	Chickens . . . . . . . . . .		     
		__________________	     	Hogs . . . . . . . . . . . . . .		     
Pasture/Rangeland Cropland Used Only For Pasture	ACRES	__________________	     	Horses . . . . . . . . . . . .		     
		__________________	     	Mules/Burros . . . . . . .		     
	     			__________________		     
Permanent Pasture . . . . . . . . . . .	     	Vegetables/Melons	ACRES	__________________		     
Woodland Pasture . . . . . . . . . . .	     	__________________	     	__________________		     
		__________________	     	__________________		     
Aquaculture	NUMBER	__________________	     		Office Use
Acres of Ponds in Use . . . . . . . .	     				TOTAL POINTS
Foodsize/Stockers . . . . . . . . . . . .	     	Berries	ACRES		552
Fingerlings/Broodfish . . . . . . . . .	     	__________________	     		PASTURE POINTS
Trout Eggs . . . . . . . . . . . . . . . . . .	     	__________________	     		554

Section 3 - VALUE of SALES (continued)

2.	Of the farm or ranch income reported, which of these categories represents the largest portion of the gross income from this operation?

Code

1 - Grains, Oilseeds, Dry Beans, and Dry Peas . . . . . . . . . . . . . . . . . . . . . . . .

1

(corn, flaxseed, grain silage and forage, grains and oilseeds, popcorn, rice, small grains, sorghum, soybeans, sunflowers, straw, etc.)

2 - Tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

3 - Cotton and Cottonseed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

4 - Vegetables, Melons, Potatoes and Sweet Potatoes. . . . . . . . . . . . . . . . . .

4

(beets, cabbage, cantaloupes, pumpkins, sweet corn, tomatoes, watermelons, vegetable seeds, etc.)

5 - Fruit, Tree Nuts and Berries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

(almonds, apples, blueberries, cherries, grapes, hazelnuts, kiwifruit, oranges, pears, pecans, strawberries, walnuts, etc.)

6 - Nursery, Greenhouse, Floriculture and Sod. . . . . . . . . . . . . . . . . . . . . . . .

6

(bedding plants, bulbs, cut flowers, flower seeds, foliage plants, mushrooms, nursery potted plants, shrubbery, sod, etc.)

7 - Cut Christmas Trees and Short Rotation Woody Crops. . . . . . . . . . . . . .

7

FARM TYPE CODE

8 - Other Crops and Hay, CRP and Pasture. . . . . . . . . . . . . . . . . . . . . . . . . . .

8

551

(grass seed, hay and grass silage, hops, maple syrup, mint, peanuts, sugarcane, sugarbeets, CRP, etc.)

9 - Hogs and Pigs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

10 - Milk and Other Dairy Products from Cows. . . . . . . . . . . . . . . . . . . . . . . . . .

10

11 - Cattle and Calves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

(beef and dairy cattle for breeding stock, fed cattle, beef and dairy cull animals, stockers and feeders, veal calves, etc.)

12 - Sheep, Goats, and their Products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

(wool, mohair, milk and cheese)

13 - Horses, Ponies, and Mules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (burros and donkeys)

13

14 - Poultry and Eggs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

(broilers, chickens, turkeys, ducks, eggs, emus, geese, hatchlings, ostriches, pigeons, pheasants, quail, poultry products, etc.)

15 - Aquaculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

(catfish, trout, ornamental and other fish, mollusks, crustaceans, etc.)

16 - Other Animals and Other Animal Products . . . . . . . . . . . . . . . . . . . . . . . . .

16

(bees, honey, rabbits, fur-bearing animals, semen, manure, other animal specialties, etc.)

Section 4 - OTHER AGRICULTURAL LABOR INFORMATION			NUMBER OF WORKERS
1. During 2015, what was or will be the largest number of hired workers, including paid family members, on the payroll on any one day?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .			277
			CODE
2 Don’t Know - [Enter code 2.] 3 None - [Enter code 3.]			278
2. During 2015, did or will this operation have any H-2A Temporary Agricultural Workers on the payroll?			CODE
1 Yes - [Enter code 1.] 2 Don't Know - [Enter code 2.] 3 No - [Enter code 3.]			279
[Skip page 11, go to back page, item 1, and continue.]

Section 5 - CHANGE IN OPERATOR

Complete this section only if you answered “NO” for all questions in item 2 on the face page.

1. Has the operation named on the label been sold, rented or turned over to someone else?

	1 Yes - [Go to item 2] 3 No - [Continue → ]					a.	Will the land be used for any agricultural purpose by you (the operator), or anyone else in the next year (including growing crops or raising livestock)?
							1 Yes 2 Don’t Know 3 No
							Regardless of answer to above, write a note to explain the situation, then go to back page, item 1.

2.	Please provide the following information for the operation that has taken over the land:
	Operation Name: _______________________________________________________________________________ Operator Name: ________________________________________________________________________________ Address: ________________________________________ Phone: (________) - _________________________ City: ______________________________________________________ State: __________ ZIP: _________

3. Was this new operation, reported in item 2, in business before June 1, 2015?

	1 Yes - [Go to back page, item 1.]
	3 No - [Continue.]

4.	Is this new operation managed?
	1 Yes - [Go to back page, item 1.]
	3 No - [Continue.]

5.

Were any individuals associated with the new operation, reported in item 2 above, operating land individually before June 1, 2015?

	1 Yes - [Go to back page, item 1.]
	3 No - [Go to back page, item 1.]

Section 6 - CONCLUSION

1. Do you (the operator named on the label) make any day - to - day decisions for ANOTHER farm or ranch?

a. 1Yes - What is the name of this other operation? . . . . . . . . . . . . . . . . . . . .	Operation Name: ________________________________________
3No - [Go to item 2 below.]	Address: __________________________________________
	City: ____________________	State:____		ZIP: ______
	Phone: (______) ____________________
[ENUMERATOR NOTE: IF ADDITIONAL OPERATION IS INDIVIDUAL OR PARTNERSHIP, complete a separate questionnaire for the additional operation.]

b. Was this additional operation in business before June 1, 2015?

1 Yes – [Continue.] 3 No – [Continue.]

COMMENTS:
2. SURVEY RESULTS: To receive the complete results of this survey on the release date, go to www.nass.usda.gov/results/.
Would you rather have a brief summary mailed to you at a later date?	1 Yes 3 No	9990

Respondent Name:

9911 Phone: (_____) _____-- __________

9910 MM DD YY Date: __ __ __ __ __ __

This completes the survey. Thank you for your help.

Office Use Only

Response

Respondent

Mode

Enum.

Eval.

Change

Office Use for POID

1-Comp 2-R 3-Inac 4-Office Hold 5-R – Est 6-Inac – Est 7-Off Hold – Est

9901

1-Op/Mgr 2-Sp 3-Acct/Bkpr 4-Partner 9-Oth

9902

1-Mail 2-Tel 3-Face-to-Face 4-CATI 5-Web 6-e-mail 7-Fax 8-CAPI 19-Other

9903

9998

9900

9985

9989  __ __ __ - __ __ __ - __ __ __

Optional Use

9907

9908

9906

9916

S/E Name