QID Agricultural Resource Management Survey (ARMS) Phase 2 C

Project 906

OMB No. 0535-0218

20xx Agricultural Resource Management
Survey (ARMS) Phase 2
Consent Form
CROP 1 Production Practices and Costs Report
CROP 2 Production Practices and Costs Report
CROP 3 Production Practices and Costs Report
CROP 4 Production Practices Report
STATE

POID

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____ ____ ____ ____ ____ ____ ____ ____ ____

Approval Expires XX/XX/20XX

NATIONAL
AGRICULTURAL
STATISTICS
SERVICE
U.S Department of Agriculture
Room 5030, South Building
1400 Independence Ave., S.W.
Washington, DC 20250-2000
Phone: 1-800-727-9540
Fax: 1-202-690-2090
Email: [email protected]

The National Agricultural Statistics Service (NASS) of the U.S. Department of Agriculture is conducting a survey of the Agricultural
Resource Management Survey (ARMS) for the 20xx crop year. The survey will be conducted from October 20xx through
December 20xx.
By signing this Consent Form, the Owner agrees to allow the caretaking company listed below to provide the necessary information
for the completion of the ARMS for the selected operation to the National Agricultural Statistics Service. In accordance with the
Confidential Information Protection and Statistical Efficiency Act of 2018, Title III of Pub. L. No. 115-435, codified in 44 U.S.C. Ch.
35 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 is he or she willfully discloses ANY identifiable information about you or your operation. Response is voluntary. Results of
the survey, showing State and National level results for the selected commodities will be available at the end of July 20xx+1.
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 0535-0218. The time required to complete this information collection is estimated to average 65 minutes
for PPCR; and 35 minutes for PPR per response. This includes the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Operation Name:

____________________________________________________________

Owner Name:

____________________________________________________________

Owner Address:

____________________________________________________________
____________________________________________________________

Owner Signature:

____________________________________________________________

Date:

________________
Operator/Owner provided consent over the telephone.

Caretaking
Company Name:

____________________________________________________________

Caretaking
Company Address:

____________________________________________________________
____________________________________________________________

Phone Number:

______________________________

NASDA Field Enumerator: __________________________________________