QID Out of Business Screener - Agribusiness

Project Code 633

OMB No. 0535-0140 Approval Expires XX/XX/XXXX

OUT OF BUSINESS SCREENER (Agribusinesses - Telephone Only)

NATIONAL AGRICULTURAL STATISTICS SERVICE

Survey Name OR Census/Survey ID: _____________________________________________________ This version will be used for Prices Paid, Grain Prices Received, Potato Processors, & other surveys where the population of interest may include non-farm/ranch agribusiness.

National Field Office U.S. Department of Agriculture, Rm 5030, South Building 1400 Independence Ave., S.W. Washington, DC 20250-2000 Phone: 1-800-727-9540 Fax: 202-690-2090 Email: [email protected]

FIPS

POID

TRACT

SUBTRACT

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The information you provide will be used for statistical purposes only. Your responses will be kept confidential and any person who willfully discloses ANY identifiable information about you or your operation is subject to a jail term, a fine, or both. This survey is conducted 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. For more information on how we protect your information please visit: https://www.nass.usda.gov/confidentiality. 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 0535-0140. 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. Operator Name:______________________________________________________

(Enumerator Note: For the target on the above POID, fill out the following information.)

3. Which of the following answers best why the operation is not in business? Check reason below.	What is the name and address of the new operator that has taken over the day-to-day decisions on this operation?
The operator is deceased	Operation Name:______________________________________
The operator is retired	Operator Name:_________________________________________
The operation was out of business or sold	Address:____________________________________________
The operation was on leased land (Operator gave up lease) [Go to Item 4]	City:_____________ State_________ Zip:________________
The operator is a landlord? (rents business out to someone else)	Phone:_________________________________
The operator moved out of state? [Specify:__________________]
The operation was never farm, ranch, or agribusiness. [Go to Item 6]
Other Reason? [Explain:__________________] [Go to Item 4]
4. When did this change occur? . . . . . . . . . . . . . . . . . . . . . . . . . . .
		MM	YYYY
5. Did this operation have any storage facilities used to store whole grains or oilseeds in 202x?
Yes [Go to Item 7]
No [Continue]
6. Will this operation have any storage facilities used to store whole grains or oilseeds in the future?
Yes [Go to Item 7]
No [Continue]
7. This Completes the Survey. Thank you for your help.
Respondent Name: _____________________ Phone ( )__________________				Date ___/______/__________
Please leave any notes that might help the List Frame Section.

Enumerator Name:	______________________________________	Enum ID:
List Frame Action Taken: ______________________________________