QID Landlord Screening Supplement

LANDLORD SCREENING SUPPLEMENT

OMB No. 0535-0213 Approval Expires: 03/31/2014 Project Code: xxx QID: SMetaKey:

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: 1-855-515-1328 Email: [email protected]

Please make corrections to name, address and ZIP Code, if necessary.

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 number is 0535-0213. The time required to complete this information collection is estimated to average 10 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.

Segment Number:____________________

Tract letter:_______________ County:_____________________

State

Stratum

Segment

Tract

__ __

__ __ __ __

000__ __ __ __ __ __

__ __ 00

Screening Supplement Form: xxx ______

In order for NASS to be able to obtain total farm expenditure data, we need to collect information relating to the expenses your landlord has incurred on the acres you rent from them. For each of the landlords from whom you rent or lease land that is located inside of the blue boundary, please tell us if you can report expenses provided by that landlord or indicate which types of expenses were incurred by that landlord. If not, please provide the contact information for each landlord. 1. How many total landlords do you rent or lease land from that is located inside of the blue boundary? xxx ____________ 2. Starting with the first of your (Item 1) landlords, can you report the actual expenses provided by this landlord? xxx 1 Yes – Go to Item 2b 3 No – Continue a. Can you indicate which types of expenses were incurred by this landlord? xxx 1 Yes –Continue 3 No –Go to Item 2c b. When would be a good time to collect this information? xxx __________________________________________________ [Go to Item 3 after a follow-up time has been determined] c. Please provide the contact information for this landlord.

Office Use Only

Landlord Contact Information

Field Identification (Name, Number, etc.)

xxx

xxx

Name: xxx _________________________________________________________ Address: xxx _______________________________________________________ City: xxx ____________________________State: xxx_______ Zip: xxx__________ Phone: xxx ________________________________________________________

3. Thinking of the next one of your (Item 1) landlords, can you report the actual expenses provided by this landlord?

^xxx 1 Yes – Go to Item 3b 3 No – Continue

a. Can you indicate which types of expenses were incurred by this landlord? ^xxx 1 Yes –Continue 3 No–Go to Item 3c

b. When would be a good time to collect this information? ^xxx _______________________________________________

[Go to Item 4 after a follow-up time has been determined]

c. Please provide the contact information for this landlord.

	Office Use Only	Landlord Contact Information
Field Identification (Name, Number, etc.)
xxx	xxx	Name: xxx _________________________________________________________ Address: xxx _______________________________________________________ City: xxx ____________________________State: xxx_______ Zip: xxx__________ Phone: xxx ________________________________________________________

4. Thinking of the next one of your (Item 1) landlords, can you report the actual expenses provided by this landlord?

^xxx 1 Yes – Go to Item 4b 3 No – Continue

a. Can you indicate which types of expenses were incurred by this landlord? ^xxx 1 Yes –Continue 3 No–Go to Item 4c

b. When would be a good time to collect this information? ^xxx _______________________________________________

[Go to Item 5 after a follow-up time has been determined]

c. Please provide the contact information for this landlord.

	Office Use Only	Landlord Contact Information
Field Identification (Name, Number, etc.)
xxx	xxx	Name: xxx _________________________________________________________ Address: xxx _______________________________________________________ City: xxx ____________________________State: xxx_______ Zip: xxx__________ Phone: xxx ________________________________________________________

5. Enumerator Action: Is Item 1 greater than 3?

^xxx 1 Yes – Complete additional screening form 3 No – Conclude Interview

Comments and Notes

OFFICE USE ONLY
	Response		Respondent		Mode		Enum.	Eval.	Change 785		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	9998	9900	9985		9989 __ __ __ - __ __ __ - __ __ __
								R. Unit			Optional Use
								9921			9907	9908		9906	9916
	S/E Name