QID 035219 Vegetable Chemical Use Survey Chemical Applications Cons

Agricultural Resource Management Phase 1 & 2 and Chemical Use Surveys

0218 - Chemical Applications Consent Form - Vegetable

OMB: 0535-0218

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Project 136 QID 035219


OMB No. 0535-0218 Approval Expires XX/XX/XXXX

20xx Vegetable Chemical Use Survey

Chemical Applications Consent Form

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]

VERSION

01

POID

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SUBTRACT

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The National Agricultural Statistics Service (NASS) of the U.S. Department of Agriculture is conducting a survey of the Vegetable Chemical Usage for the 20xx crop year. The survey will be conducted from October, 20xx through January, 20xx+1.


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 (Title III of Pub. L. No. 115-435, codified in 44 U.S.C. Ch. 35), 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, 20xx+1.



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.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCarol Pinto
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File Created2023-09-15

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