QID Pesticide Safety Practices Screener

PESTICIDE SAFETY PRACTICES SCREENER – October 2014

			OMB No. xxxx-xxxx Approval Expires: x/xx/xxxx Project Code: xxx QID: xxxxxx SMetaKey: xxxx
				NATIONAL AGRICULTURAL STATISTICS SERVICE

Please make corrections to name, address and ZIP Code, if necessary. We are collecting information on pesticide safety practices and the factors that contribute to them. We need your help to make this information as accurate as possible. 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 in combination with similar reports from other producers. 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 for this information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 15 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.

I would like to talk to you about any recent chemical pesticides (e.g., insecticides, rodenticides, fungicides, herbicides, growth regulators, or fumigants) you personally applied for crop production in your business. We are only interested in those pesticides you may have applied using methods other than aerial applications (such as with airplanes or helicopter) and enclosed cab vehicles (such as tractors and ATVs). Please respond to the 2 items below --

1. Have you personally applied any chemical pesticides in the past 6 months using methods other than aerial applications (such as with airplanes or helicopter) and enclosed cab vehicles (such as tractors and ATVs)? (check one)

1 ­______Yes – Continue 2 __ No – Sign, date, and return form in the postage-paid envelope

2. Please complete the table below. Please indicate the name and EPA registration numbers of the 3 most recent chemical pesticides you personally applied within the past 6 months, using methods other than an aerial applications (such as with airplanes or helicopter) and enclosed cab vehicles (such as tractors and ATVs)? Please also provide approximate dates (month/year) each pesticide was purchased and applied.

	Exact Name of Chemical Pesticide Product (Include any formulation identifiers, e.g., Harness 20G, Harness 5.6L, etc.)	EPA Registration Number (Usually on the front of label after the active ingredients)	Date of Pesticide Purchase	Date of Pesticide Application
1		xxxx	xxxx Month/Year: ____ / ____ MM / YY	xxxx Month/Year: ____ / ____ MM / YY
2		xxxx	xxxx Month/Year: ____ / ____ MM / YY	xxxx Month/Year: ____ / ____ MM / YY
3		xxxx	xxxx Month/Year: ____ / ____ MM / YY	xxxx Month/Year: ____ / ____ MM / YY

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

Product Code 3

xxxx

Product Code 2

xxxx

Product Code 1

xxxx

Comments:

That completes our survey. Thank you for your help

We may need additional information later in 2014 to complete this study. If so, we will contact you in November or December to set up a time that is good for you.

	Respondent Name:	9911 Phone:	9910 MM DD YY Date:

For questions or concerns, please contact __________________ at ____________________.

Response		Respondent		Mode		Enum.	Eval.	R. Unit	Change	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	098	100	921	785	789 __ __ __ - __ __ __ - __ __ __
										Optional Use
										407	408		9906	9916
S/E Name

Office Use Only