NAHMS 314 General Dairy Management Questionnaire CATI

United States Department of Agriculture	GENERAL DAIRY MANAGEMENT Questionnaire CATI January 2014
OMB No. 0579-0205 Approval Expires: XX/XXXX Project Code: 930 NAHMS 314 QID: xxxxxx SMetaKey: xxxx		Animal and Plant Health Inspection Service 2150 Centre Ave., Bldg. B Fort Collins, CO 80526-8117

	Office Use Only
	0001
BEGINNING TIME [MILITARY]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	0002 __ __ __ __
INTRODUCTION
[Rephrase in your own words.] We would like to ask you some questions about your dairy operation. To understand important issues in the dairy industry, we need to obtain information about the health status of your dairy cattle, any health problems they may have had, as well as about productivity and management. 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. However, your report is needed to make regional and national estimates as accurate as possible. You may find it easier to answer some of the questions if you have your records available.

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 information collection is 0579-0205. The time required to complete this information collection is estimated to average .5 hours 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.

SECTION 1 – INVENTORY, RECORD KEEPING & PRODUCTIVITY

1. Enumerator Note: Were any dairy cows (IC 352) reported on the Cattle or Milk Report?

^xxx ₁  Yes – Continue ₃  No – Go to Section 10

Instructions: If the respondent completed the Cattle Report:

• Transfer items 2 – 6

• Ask items 7 – 11

OR

If the respondent only completed the Milk Report:

• Transfer items 2 – 4

• Ask items 5 – 11

Head

352

2. The number of dairy cows on hand January 1 (IC 352) from the Cattle or

Milk Report: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

349

3. The number of dairy cows milked on this operation on January 1 (IC 349)

from the Cattle or Milk Report: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gallons		Pounds
502 Gals.	OR	501 Lbs.

4. The amount of milk produced (IC 502 or IC 501) on

January 1 from the Cattle or Milk Report: . . . . . . . . . .

Head

353

5. How many bulls weighing 500 pounds or more were on hand January 1, 2014?

355

6. How many heifers weighing 500 pounds or more for dairy cow replacement

were on hand January 1, 2014? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Head

xxx

xxx

7. Of the (item 2) dairy cows on hand January 1, how many were:

a. Lactating cows? . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Dry cows? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

xxx

8. Of the (item 5) bulls weighing 500 pounds or more on hand January 1, how many were dairy +

bulls used for breeding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Of the dairy replacement heifers on hand on

xxx

xxx

xxx

January 1, how many were:

a. Preweaned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

b. Weaned but not pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

c. Pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +

xxx

10. So the total dairy inventory on hand January 1, 2014 was?

[Add Items 7a + 7b + 8 + 9a + 9b + 9c and verify the total.] TOTAL =

SECTION 1 – INVENTORY, RECORD KEEPING & PRODUCTIVITY

11. Of the (item 2) dairy cows on this operation January 1, 2014, what percent were: Percent

a. Holstein?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xxxx %
b. Jersey?	+	xxxx %
c. Ayrshire?	+	xxxx %
d. Brown Swiss?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	+	xxxx %
e. Guernsey?	+	xxxx %
f. Other, including mixed dairy breeds? (Specify: xxxx_______________________________)	+	xxxx %

TOTAL = 100%

Percent

12. Of the (item 2) dairy cows, what percent are registered with a breed association (purebred)?

xxxx %

13. In order to track the inventory changes during 2013, how many: Head

a. Lactating and dry cows were present on January 1, 2013?. . . . . . . . . . . . . . . . . . . . . . . . .		xxxx
b. Natural additions added to the milking herd during 2013? (Include heifers raised offsite)	+	xxxx
c. Purchased/leased additions added to the milking herd during 2013?	+	xxxx
d. Adult cows were permanently removed from the herd during 2013? (Exclude cows that died)	-	xxxx
e. Adult cows died during 2013?	-	xxxx
f. Total lactating and dry cows were present on January 1, 2014? (should = Item 2)	=	xxxx

Head

xxxx

xxxx

14. How many cows did this operation milk 5 years ago?

15. How many cows does this operation anticipate milking in 5 years?

16. During 2013, did this operation participate in any of the following types of quality assurance

programs to improve product quality through assessments and monitoring?

a. State sponsored program?

b. Local milk cooperative/processor sponsored program?

c. National industry sponsored program?

d. Other program? (Specify: ^xxxx ______________________________________________)

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

17. Of the (item 2) dairy cows on hand January 1, what percent had the individual types of individual cow identification?

a. Unofficial ID (e.g bangle, RFID – 900 series, leg bands, collars, brand, other) ______%

b. Official (e.g. Brucellosis (Bang’s) orange metal or Official silver (brite),

or Visual AIN tag (“840” or “USA” prefix) metal eartag, Electronic (RFID button, “840” prefix),

Visual AIN tag (“840” prefix) with RFID) _______%

SECTION 1 – INVENTORY, RECORD KEEPING & PRODUCTIVITY

18. During 2013, which of the following types of record keeping systems did this operation

use to track individual dairy animals?

a. Handwritten records such as a ledger or notebook?

b. Dairy Herd Information Association (DHIA)?

c. Off-farm computer record system other than DHIA?

d. On-farm computer record system?

e. No record keeping system?

f. Other systems? (Specify: ^xxxx _____________________________________________)

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

^xxxx ₁  Yes ₃  No

19. During 2013, did this operations management have access to the internet? ₁ Yes ₃ No

Head

xxxx

20. During 2013, what percent of cows (item 2) received bST (bovine somatotropin, trade name Posilac^®) this lactation?

Pounds per Cow

xxxx

21. What is the current rolling herd average (RHA) for milk production?

22. During 2013, how many times per day were the majority of cows milked? (Check one)

^xxxx

1 Once a day

2 Twice a day

3 Three times a day

4 More than three times a day

CWT

xxxx

23. During 2013, how much milk was produced by this operation? (Report in hundredweight)

24. Which one of the following practices best described this dairy operation during 2013? (Check one)

^xxxx

1 Conventional (majority of forage consumed is not harvested by cows)

2 Grazing (majority of forage consumed is harvested by cows)

3 Combination of conventional and grazing

4 Organic (operation meets USDA organic standards)

5 Other? (Specify: ^xxxx __________________________________________________)

SECTION 2 – BIOSECURITY, MOVEMENT & REARING PRACTICES

1. Were any cattle brought onto this operation during 2013? (Include purchased, leased, or borrowed cattle. Exclude

calves raised off-site and returned to this operation.)

^xxxx ₁  Yes - Continue ₃  No – Go to Item 4
any diseases?
tire question

2. During 2013, before bringing cattle (either dairy or beef) onto the farm, did this operation normally require individual animal testing for any diseases? ^xxxx ₁  Yes ₃  No

SECTION 2 – BIOSECURITY, MOVEMENT & REARING PRACTICES

3. During 2013, before bringing cattle (either dairy or beef) onto the farm, did this operation normally require vaccination for any diseases? ^xxxx ₁  Yes ₃  No

4. During 2013, which of the following animals were either on this operation at any time or on adjacent

operations where fence-line contact was possible?

Animal type	On this operation during 2013?	On an adjacent operation during 2013 where fence-line contact was possible?
a. Dairy cattle		xxxx 1  Yes 3  No
b. Beef cattle	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
c. Mexican-origin cattle (e.g., steers, rodeo stock)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
d. Chickens or other poultry	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
e. Horses, donkeys, mules, etc.	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
f. Pigs (domestic)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
g. Sheep	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
h. Goats	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
i. Dogs (domestic or feral)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
j. Cats (domestic or feral)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
k. Captive deer or elk	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
l. Llamas or alpacas	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
m. Bison	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
n. Other (Specify: xxxx ______________________)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No

5. During 2013, how frequently were the following wild animal or signs of wild animals (scat, tracks, etc.)

observed on this operation?

Never Less than once More often than

a month once a month

a. Deer?

b. Coyotes or foxes?

c. Raccoons?

d. Opossums?

e. Skunks?

f. Feral pigs?

g. Other wild animals? (Specify: ^xxxx ____________________________________)

^xxxx

₁  ₂  ₃ 

^xxxx

₁  ₂  ₃ 

^xxxx

₁  ₂  ₃ 

^xxxx

₁  ₂  ₃ 

^xxxx

₁  ₂  ₃ 

^xxxx

₁  ₂  ₃ 

^xxxx

₁  ₂  ₃ 

[If Item 5a = Never, Skip to section 3; otherwise continue]

SECTION 2 – BIOSECURITY, MOVEMENT & REARING PRACTICES

6. How frequently were deer observed in the cattle-housing areas, pastures, or lots?

^xxxx ₁  Never

₂  Less than once a month

₃  Monthly

₄  Weekly or daily

SECTION 3 – COLOSTRUM & PREWEANED CALF MANAGEMENT

1. During 2013, what percent of calves were:

Percent

a. hand-fed colostrum only . . . . . . . . . . .		xxxx %
b. hand-fed colostrum and allowed to suckle?	+	xxxx %
c. not hand-fed colostrum and allowed to suckle?	+	xxxx %

TOTAL = 100%

Hours

Minutes
xxxx	OR

2. During 2013, in general how many minutes or hours after birth were heifer calves permanently separated from their dams?

3. During 2013, did this operation estimate immunoglobulin (IgG) levels in, or quality of

colostrum, such as through use of a colostrometer? ^xxxx ₁  Yes ₃  No

4. How did newborn dairy heifer calves normally get their first feeding of colostrum?

^xxxx

1 Suckling the dam

2 Hand feeding from bucket or bottle

3 Hand feeding using esophageal feeder

4 Other (Specify: ^xxxx _____________________________________________)

5. During 2013, did this operation routinely monitor serum proteins as a measure of passive

transfer status of newborn dairy heifer calves? ^xxxx ₁  Yes ₃  No

6. During 2013, were dairy heifer replacements routinely tested for BVD? ^xxxx ₁  Yes ₃  No

7. During 2013, what percent of preweaned dairy heifer calves received the following

liquid diets prior to weaning? Percent

a. Nonmedicated milk replacer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xxxx %
b. Medicated milk replacer	+	xxxx %
c. Unpasteurized saleable or non-saleable waste milk	+	xxxx %
d. Pasteurized saleable or non-saleable waste milk. . . . . . . . . . .	+	xxxx %
e. Other (Specify: xxxx _________________________________________________)	+	xxxx %

TOTAL [will be greater than 100% if calves received more than one diet] = ≥100%

[If Item 7a and 7b both equal zero, go to Item 9; otherwise continue]

SECTION 3 – COLOSTRUM & PREWEANED CALF MANAGEMENT

Percent of Protein	AND	Percent of Fat
xxxx %		xxxx %

8. What percent of protein and fat was in the milk replacer fed to the majority

of dairy heifers in 2013?

9. During 2013, how many times per day was milk or milk replacer routinely fed to calves? (Check one)

^xxxx

1 Once daily

2 Twice daily

3 Three times daily

4 Other (Specify: ^xxxx ________________________________________________)

Quarts

xxxx

10. During 2013, how many quarts of milk or milk replacer were routinely fed to each

calf at each feeding?

11. During 2013, what percent of preweaned dairy calves received the following medications in milk replacers?

Percent

a. Aureomycin® (Chlortetracycline). .		xxxx %
b. Terramycin® (Oxytetracycline)	+	xxxx %
c. NT, Neo-Terra® , Neo-Oxy (Neomycin and Oxytetracycline)	+	xxxx %
d. Deccox® (Decoquinate). . . . . . . . . . .	+	xxxx %
e. Bovatec® (Lasalocid)	+	xxxx %
f. Other (Specify: xxxx ________________________________________________)	+	xxxx %

12. During 2013, what was the average age in days of dairy heifers when they were first offered:

Days

a. Water?		xxxx
b. Starter grain or other concentrates?		xxxx
c. Hay or other roughages?		xxxx

Days		Weeks
xxxx	OR	xxxx

13. What was the average age, in days or weeks, that dairy

heifers were weaned during 2013?

SECTION 4 – FEEDING & PREVENTATIVE PRACTICES

1. During 2013, did this operation use forage test results to balance feed rations? ^xxxx ₁  Yes ₃  No

2. Did this operation feed a total mixed ration (TMR)? ^xxxx ₁  Yes ₃  No

3. Did this operation separate close-up cows from other dry cows? ^xxxx ₁  Yes ₃  No

4. During 2013, which of the following best describes how frequently leftover feed (weigh backs) from older cattle

were fed back to younger heifers?

^xxxx

1 Daily or weekly

2 A couple of times per month

3 Less than monthly

SECTION 4 – FEEDING & PREVENTATIVE PRACTICES

5. During 2013, what percent of cattle received water from the following water sources?

Percent

a. Ground water (well). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .				xxxx %
b. Surface water (ponds, lakes, streams)		+		xxxx %
c. Municipal water supply (treated water)		+		xxxx %
	TOTAL [will be greater than 100% if more than one water source] =			≥100%

6. During 2013, did this operation perform any water quality testing (e.g., bacteria, minerals, etc.) of cattle drinking water?

^xxxx ₁  Yes ₃  No

7. During 2013, were any dairy cows vaccinated against any disease? ^xxxx ₁  Yes ₃  No

8. During 2013, were any dairy cows vaccinated against rabies? ^xxxx ₁  Yes ₃  No

9. Were all dairy cows vaccinated against BVD annually? ^xxxx ₁  Yes ₃  No ₄  NA

10. During 2013, did this operation normally use the following preventative practices for heifers or cows?

Preventative practice	Heifers	Cows
	No heifers on farm during 2013? xxxx 1 Skip to next column
a. Dewormers	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
b. Rumensin®, Bovatec® in feed (Ionophores)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
c. Vitamin A-D-E (injectable or feed additive)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
d. Selenium (injectable or feed additive)	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
e. Probiotics	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No
f. Anionic salts	xxxx 1  Yes 3  No	xxxx 1  Yes 3  No

SECTION 5 – HOUSING

1. Which of the housing types listed below was the primary housing type used during 2013 for each of the following classes

of cattle while on this operation?

Housing type codes
1 = Individual outside hutch/pen	7 = Freestall with access to open lot
2 = Individual inside hutch/pen – warm (heated) calf barn	8 = Open lot/multiple animal outside area without barn or shed (with or without shade structures)
3 = Individual inside hutch/pen – cold (nonheated) calf barn	9 = Open lot with open shed/loafing shed
4 = Tie stall or stanchion	10 = Multiple animal inside area/barn
5 = Pasture	11 = Other (Specify: xxxx ___________________)
6 = Freestall with no access to open lot	12 = Not housed on this operation

Code

a. Preweaned dairy heifers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xxxx
b. Weaned dairy heifers		xxxx
c. Pregnant dairy heifers		xxxx
d. Lactating cows . . . . . . . . . .		xxxx
e. Dry cows		xxxx

[If Item 1a = 1, continue; otherwise, go to Item 3]

2. Were preweaned heifers provided extra bedding and/or a wind break during the winter months? ^xxxx ₁  Yes ₃  No

3. Was maternity housing separate from housing used for lactating dairy cows? ^xxxx ₁  Yes ₃  No

4. During 2013, what was the primary milking facility used on this operation? (Check one)

^xxxx

1 Parlor milking facilities

2 Tie stall or stanchion barn milking facilities

3 Other type of milking facility (Specify: ^xxxx___________________________________)

5. During 2013, were the following classes of cattle allowed on pasture owned or operated by this operation?

Animal type	Allowed on pasture during 2013?
a. Weaned heifers xxxx 1 No weaned heifers on farm in 2013	xxxx 1  Yes 3  No
b. Pregnant heifers xxxx 1 No pregnant heifers on farm in 2013	xxxx 1  Yes 3  No
c. Lactating cows	xxxx 1  Yes 3  No
d. Dry cows xxxx 1 No dry cows on farm in 2013	xxxx 1  Yes 3  No

SECTION 5 – HOUSING

For the next couple of questions, “outside area” refers to areas without permanent roof structures but can have permanent shade structures.

6. Which of the following best describes the primary outside area that lactating cows routinely had access to during the

summer and winter seasons? (Enter only one code for each season.)

Outside area codes (Items 6 & 7)
1 = Pasture	4 = No outside access
2 = Concrete alleyway or pen	5 = Other (Specify: xxxx ___________________)
3 = Open/Dry lot	6 = No dry cows on farm in 2013

Code

a. Summer season . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xxxx
b. Winter season		xxxx

7. Which of the codes above best describes the primary outside area that dry cows routinely had access to during the

summer and winter seasons? (Enter only one code for each season.)

Code

a. Summer season . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .		xxxx
b. Winter season		xxxx

8. Which of the following is the predominant flooring type that lactating cows stand or walk on when not being milked,

excluding concrete adjacent to the feed bunk? (Check one)

^xxxx

1 Concrete – groove/textured

2 Concrete – slat

3 Concrete – smooth

4 Pasture

6 Dirt

7 Other (Specify: ^xxxx ___________________________________________________)

SECTION 6 – USE OF VETERINARIANS

1. During 2013, did this operation work with or consult a veterinarian?

^xxxx ₁  Yes – Continue ₃  No – Go to Section 7

2. During 2013, how frequently was the veterinarian on this operation?

^xxxx

1 Daily

2 Weekly

3 Monthly

4 Less than monthly

SECTION 7 – MANAGEMENT OF NONAMBULATORY CATTLE AND EUTHANASIA

Nonambulatory cattle are those that are unable to stand for any period of time. This includes cattle that are temporarily unable to stand (such as milk fever cases or cows with leg injuries). Nonambulatory cattle also include ‘Downer’ animals, whether these animals die or recover.

Head

xxxx

1. How many dairy cows became nonambulatory during 2013?

If 0, skip to item 3

2. During 2013, was assistance offered to nonambulatory cows to help them rise (e.g., hoist or flotation tank)?

^xxxx ₁  Yes ₃  No

3. Were any cows euthanized on this operation during 2013? ^xxxx ₁  Yes ₃  No

Section 8—Nutrient Management

1. Are the following manure-handling methods used in

cow and weaned-heifer housing areas?

Weaned-Heifer Areas

If heifers not kept on

operation, check

here and leave

Cow Areas column blank: _____

a. Manure left on pasture S233/243 ₁ Yes ₂ N/A ₃ No ₁ Yes ₂ N/A ₃ No

b. Dry lot scraped S234/244 ₁ Yes ₂ N/A ₃ No ₁ Yes ₂ N/A ₃ No

c. Gutter cleaner S235/245 ₁ Yes ₃ No ₁ Yes ₃ No

d. Alley scraper (mechanical or

tractor) S236/246 ₁ Yes ₃ No ₁ Yes ₃ No

f. Alley flush with recycled water S238/248 ₁ Yes ₃ No ₁ Yes ₃ No

g. Slotted floor S239/249 ₁ Yes ₃ No ₁ Yes ₃ No

h. Bedded pack (manure pack) S240/250 ₁ Yes ₃ No ₁ Yes ₃ No

i. Manure vacuum S241/251 ₁ Yes ₃ No ₁ Yes ₃ No

j. Other (specify: _______)S242OTH S242/252 ₁ Yes ₃ No ₁ Yes ₃ No

2. Of the manure-handling methods used in the previous

question, which one best describes how the majority

of manure is handled? S253/254 _____ letter _____ letter

Cow area Weaned-heifer area

(Enter letter that corresponds with response, i.e., “a” for Manure left on

pasture, “c” for Gutter cleaner, etc.)

SECTION 9 – CONCLUSION

Survey results can be found by accessing www.aphis.usda.gov/animal_health/nahms/ Would you prefer to receive reports as hard copies via the mail? . . . . . . . . . . . . . . . . . . . . . . . . . .
	0099	1 Yes 3 No
1. Request signature on CONSENT FORM for operations completing this questionnaire.
2. If CONSENT FORM is signed, provide comments below to describe the respondent location and any other comments that will be helpful for future contact.

3. ENTER INTERVIEW RESPONSE CODE
	1 - No dairy cows on January 1, 2014; not eligible for this survey 2 - Out of business 3 - Refusal of General Dairy Management Questionnaire 4 - Complete: signed VMO consent 5 - Complete: refused VMO consent 6 - No dairy cows but other cattle and calves on January 1, 2014; complete Cattle Report 7 - Out of scope for General Dairy Management Questionnaire 8 - Office hold 9 - Inaccessible	Code
		2000

[If Item 3 = 3 or 5, complete Item 4; otherwise SKIP to Ending Time.]

4. ENTER REFUSAL REASON CODE
	1 - Does not want to commit time to the project 2 - Does not want involvement with government veterinarian 3 - Does not have necessary records available 4 - Has participated in too many surveys 5 - Does not want outside people on the dairy operation 6 - A bad time of year due to planting, harvesting, second job, etc. 7 - Currently has or recently had disease problem with herd 8 - Believes that surveys and reports hurt the farmer more than help 9 - Could not get Owner/Contractor permission 10- No reason given, or other miscellaneous reasons	Code
		2001
ENDING TIME [MILITARY]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .			2002 ___ ___ ___ ___

Respondent Name:					9911 Phone: ( )				9910 MM DD YY Date: __ __ __ __ __ __
Response		Respondent		Mode		Enum.	Eval.	Rpt. Unit	Office Use for POID
1-Comp 2-R 3-Inac 4-Office Hold 5-R – Est 6-Inac – Est 7-Off Hold – Est 8-Known Zero	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	0098	0100	0921	0789 __ __ __ - __ __ __ - __ __ __
									Optional Use
									0407	0408
S/E Name