NAHMS-236 Poultry 2010 Breeder Questionnaire

National Animal Health
Monitoring System
2150 Centre Ave Bldg B
Fort Collins, CO 80526
Animal and
Plant Health
Inspection
Service
Veterinary
Services

Form Approved
OMB Number 0579-XXXX
Expires

Poultry 2010
Breeder Questionnaire

Please complete a separate Breeder Farm Questionnaire for each Primary Breeder farm or Multiplier farm
selected to participate in the Breeder Farm phase of the study. Please note that sections D and F may
need to be completed by someone who is familiar with the health status of the farm.
Goals:
1. Describe breeder farm level biosecurity practices to inform disease transmission models and
provide information to make bird/product movement decisions during disease incidents.
2. Identify critical biosecurity practices for exclusion of Mycoplasma or other diseases.
Definitions:
Farm: A premises with one or more poultry house(s) under common management.
Flock: A group of birds housed together in one house and managed as a unit.
Primary breeder flock: A breeding flock that produces chicks that will become breeding birds
(grandparent and above).
Multiplier (parent) flock: A breeding flock that produces chicks that will become broilers and table
egg layers.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
resond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0579-XXXX. The time required to complete this information collection is estimated to average 0.5
hours per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collected.

NAHMS-236
May 2010
1

Section A. Farm Information
1. What type of farm is this? [Check one only.]
†1 Primary breeder—broiler (meat-type) breeders
†2 Primary breeder—layer (egg-type) breeders
†3 Multiplier/parent—broiler (meat-type) breeders
†4 Multiplier/parent—layer (egg-type) breeders
[If Item 1 = 2, 3 or 4 then SKIP to Item 3.]
2. If this is a primary breeder farm, does this farm contain:
a. Pedigree (Elite/foundation)? ..........................................................................

†1 Yes

†3 No

b. Great grandparent (GGP)? ............................................................................

†1 Yes

†3 No

c.

†1 Yes

†3 No

a. Fencing surrounding the farm ........................................................................

†1 Yes

†3 No

b. Signs posted (e.g., no trespassing) ...............................................................

†1 Yes

†3 No

c.

†1 Yes

†3 No

Grandparent (GP)? ........................................................................................

3. Is this farm company-owned or under contract? [Check one only.]
†1 Company-owned
†2 Contract
4. Who owns the birds on this farm? [Check one only.]
†1 Breeder company
†2 Broiler company
†3 Table egg company
†4 Other (specify: ____________________________________)
5. Which of the following perimeter controls are characteristics of the farm?

Gated entrance ..............................................................................................

6. Which best describes the road surface on this farm that vehicles coming
onto the operation drive on? [Check one only.]
†1 Hard top/asphalt
†2 Gravel
†3 Dirt
†4 Other (specify: _______________________________)

2

7. For each type of vehicle in the following list, indicate which
procedures are required when the vehicle visits this farm.
[Check all procedures that apply.]
Procedure

Recorded in
vehicle log

Tires sprayed
before
entering
farm

Tires sprayed
before
leaving
farm

Must park at
least 100 ft
from bird
houses

a. Feed delivery vehicle

†1

†2

†3

†4

b. Vehicle for moving
birds onto operation

†1

†2

†3

†4

†1

†2

†3

†4

d. Vehicle for removing eggs

†1

†2

†3

†4

e. Vehicle of service
tech or vet

†1

†2

†3

†4

†1

†2

†3

†4

c.

f.

Vehicle for moving
birds off operation

Vehicle(s) for catch
crews/vaccination crews
† No catch or vaccination crews

8. Which of the following best describes how eggs are gathered on this farm? [Check one only.]
†1 Hand only
†2 Belt only
†3 Both hand and belt
9. Which of the following best describes how floor eggs are handled?
Sent to hatchery

Sent to breaker

Discarded

a. Clean eggs

†1

†2

†3

b. Dirty eggs

†1

†2

†3

c.

†1

†2

†3

Broken eggs

10. Which of the following best describes the birds’ drinking water supply for this farm?
[Check one only.]
†1 Surface water
†2 Well water
†3 Municipal water system
†4 Other (specify: ____________________________________)
[If Item 10 = 3, SKIP to Item 12.]
11. Is drinking water sanitized (chlorination, peroxide, etc.)? ....................................

†1 Yes

†3 No

3

12. At the completion of a flocks’ laying cycle is litter:
a. Reused by another flock? .............................................................................
If YES, how many flocks typically use the same litter?..................................
b. Stored on farm? .............................................................................................
If YES, distance to nearest poultry house .....................................................

†1 Yes

†3 No

_____ flocks
†1 Yes

†3 No

_____ feet

Applied to land on this farm? .........................................................................

†1 Yes

†3 No

d. Moved off farm? .............................................................................................

†1 Yes

†3 No

†1 Yes

†3 No

a. Litter/manure from another farm, same company..........................................

†1 Yes

†3 No

b. Litter/manure from another farm, different company .....................................

†1 Yes

†3 No

c.

13. Is litter/manure from another farm applied to land on this farm?
If YES,

Section B. House Information
1. How many bird houses are on this farm?..........................................................

_____ houses

2. How many of these houses are:
a. Less than 5 years old? ................................................................................

_____ houses

b. 5 to 9 years old?..........................................................................................

_____ houses

c.

10 to 19 years old?......................................................................................

_____ houses

d. 20 years old or older? .................................................................................

_____ houses

e. Total [should equal Item 1.] ........................................................................

_____ houses

3. How many of these houses have:
a. Locks on the doors?.......................................................................................

_____ houses

b. An anteroom that personnel must enter through that separates
“outside area” from “inside area”?..................................................................

_____ houses

c.

_____ houses

A warning sign at house door? ......................................................................

4. Which best describes the ground surface immediately surrounding
the poultry houses (excluding vehicle approach and loading area)? [Check one only.]
†1 Gravel or hard surface
†2 Dirt
†3 Short grass
†4 Tall grass or brush

4

5. How frequently are the following procedures performed?
After every
Flock

After two
flocks

After three
or more flocks

Never

a. Wash feeders

†1

†2

†3

†4

b. Disinfect feeders

†1

†2

†3

†4

c.

Wash water tanks

†1

†2

†3

†4

d. Disinfect water tanks

†1

†2

†3

†4

e. Flush water lines

†1

†2

†3

†4

f.

Disinfect water lines

†1

†2

†3

†4

g. Dry clean walls/ceilings

†1

†2

†3

†4

h. Houses washed down
and disinfected

†1

†2

†3

†4

†1

†2

†3

†4

i.

Clean fans, ventilation
system, cool cells

6. What is the usual down time between flocks? .......................................................

_____ days

Section C. Animals
1. How many of the following birds are on this farm today:
a. Pullets? ..........................................................................................................

_____ head

b. Laying hens?..................................................................................................

_____ head

c.

Young roosters?.............................................................................................

_____ head

d. Breeding roosters?.........................................................................................

_____ head

2. Which of the following best describes the bird age grouping on this farm?
[Check one only.]
†1 Multi-age, same house
†2 Different ages, different houses
†3 Whole farm, one age
3. For the last completed laying flock, what was the:
a. Age of hens when they were placed (weeks)? ..............................................

_____ weeks

b. Number of hens placed? ................................................................................

_____ hens

c.

Total number of hens that died (cumulative mortality)
for the life of the flock? ...................................................................................

_____ hens

d. Number of deaths that occurred at or before 60 weeks of age? ...................

_____ hens

e. Number of times flock was molted? ...............................................................

_____ times

f.

Age removed (weeks)? ..................................................................................

_____ weeks

5

4. Which of the following best describes this farm’s usual spent hen disposal method?
[Check one only.]
†1 Processing
†2 Rendering
†3 Composting
†4 Burial
†5 Live bird market
†6 Other (specify: ________________________________)
5. Which of the following best describes this farm’s usual carcass (daily mortality)
disposal method? [Check one only.]
†1 Rendering
†2 Composting on-site
†3 Burial on-site
†4 Incineration on-site
†5 Other (specify: ____________________________)
6. Are the following types of animals on this farm?
a. Cattle ..............................................................................................................

†1 Yes

†3 No

b. Pigs ................................................................................................................

†1 Yes

†3 No

c.

Other livestock ...............................................................................................

†1 Yes

†3 No

d. Pet birds .........................................................................................................

†1 Yes

†3 No

e. Other pets (dogs, cats, etc.)...........................................................................

†1 Yes

†3 No

7. On a scale of 1 – 5 (1 = never, 5 = daily), during the last 3 months, how
frequently were the following animals seen in the poultry houses?
Never

Daily

a. Rodents.................................................................................

†1

†2

†3

†4

†5

b. Wild birds .......................................................................

†1

†2

†3

†4

†5

c.

Cats ................................................................................

†1

†2

†3

†4

†5

d. Dogs ...............................................................................

†1

†2

†3

†4

†5

e. Wild mammals (raccoon, opossum, etc.).......................

†1

†2

†3

†4

†5

8. During the previous 12 months, were any of the following methods
of rodent control used on this operation?
a. Chemicals or bait ...........................................................................................

†1 Yes

†3 No

b. Traps or sticky tape........................................................................................

†1 Yes

†3 No

c.

Cats ................................................................................................................

†1 Yes

†3 No

d. Exterminator...................................................................................................

†1 Yes

†3 No

e. Other (specify: __________________________) .........................................

†1 Yes

†3 No

6

9. During the previous 12 months, were any of the following methods
of insect control used on this operation?
a. Insecticide sprays...........................................................................................

†1 Yes

†3 No

b. Sticky tape......................................................................................................

†1 Yes

†3 No

c.

Parasites (e.g., insect parasitic nematodes) ..................................................

†1 Yes

†3 No

d. Fly baits ..........................................................................................................

†1 Yes

†3 No

e. Other (specify: __________________________) .........................................

†1 Yes

†3 No

Section D. Bird Health and Vaccination
1. Using a scale of severe, moderate, minor, or no problem, rate this
farm’s problem with the following diseases for the last completed flock:
Severe

Moderate

Slight

None

a. Mycoplasma synoviae (MS)?

†1

†2

†3

†4

b. Mycoplasma gallisepticum (MG)?

†1

†2

†3

†4

c.

†1

†2

†3

†4

d. Newcastle disease?

†1

†2

†3

†4

e. Infectious bronchitis?

†1

†2

†3

†4

f.

Infectious coryza?

†1

†2

†3

†4

g. Marek’s disease?

†1

†2

†3

†4

h. Coccidiosis?

†1

†2

†3

†4

i.

Avian influenza (AI)?

†1

†2

†3

†4

j.

E. coli peritonitis?

†1

†2

†3

†4

k.

Other? (specify: _____________)

†1

†2

†3

†4

<12 mo

1 to 3 yr

>3 yr

Never

a. Mycoplasma synoviae (MS)?

†1

†2

†3

†4

b. Mycoplasma gallisepticum (MG)?

†1

†2

†3

†4

c.

†1

†2

†3

†4

d. Newcastle disease?

†1

†2

†3

†4

e. Infectious bronchitis?

†1

†2

†3

†4

f.

Infectious coryza?

†1

†2

†3

†4

g. Marek’s disease?

†1

†2

†3

†4

h. Coccidiosis?

†1

†2

†3

†4

i.

Avian influenza (AI)?

†1

†2

†3

†4

j.

E. coli peritonitis?

†1

†2

†3

†4

k.

Other? (specify: ______________)

†1

†2

†3

†4

Infectious laryngotracheitis (ILT)?

2. When did this farm last experience any cases
of the following diseases:

Infectious laryngotracheitis (ILT)?

7

3. How many times was the last completed flock tested for the following diseases,
and how many times was there at least one positive test result?
[If not tested, enter 0.]
Times
Times
Tested
positive
a. Pullorum-typhoid

_____

_____

b. Mycoplasma synoviae (MS)

_____

_____

c.

_____

_____

_____

_____

Mycoplasma gallisepticum (MG)

d. Avian influenza (AI)?

4. Does this farm participate in the following NPIP programs:
a. Pullorum-typhoid ............................................................................................

†1 Yes

†3 No

b. Mycoplasma synoviae (MS)...........................................................................

†1 Yes

†3 No

c.

Mycoplasma gallisepticum (MG)....................................................................

†1 Yes

†3 No

d. Avian influenza ..............................................................................................

†1 Yes

†3 No

5. How many times are the following vaccines given to breeding hens
before they enter the laying house (e.g., as pullets) and after entering
the layer house (in lay)?
As pullets

In lay

____

____ times

† Vector

† Other

b. Mycoplasma synoviae (MS)........................................................

____

____ times

c.

Mycoplasma gallisepticum (MG).................................................

____

____ times

d. Cholera........................................................................................

____

____ times

e. Newcastle disease ......................................................................

____

____ times

f.

Infectious bronchitis ....................................................................

____

____ times

g. Salmonella ..................................................................................

____

____ times

h. Infectious bursal disease (IBD) ...................................................

____

____ times

a. Infectious laryngotracheitis (ILT).................................................
If given, what type of vaccine was used:
† Chick embryo

† Tissue culture

If given,
What type of vaccine was used?
† Killed (Inactivated)

† Live

† Modified Live

† Recombinant

† Other

What type of delivery system was used?
† Spray

† Water

† Individual Injection

† In ovo

† Other

i.

Avian encephalomyelitis

____

____ times

j.

E. coli...........................................................................................

____

____ times

k.

Chicken anemia virus..................................................................

____

____ times

l.

Reovirus ......................................................................................

____

____ times

m. Coccidiosis ..................................................................................

____

____ times

n. Other (specify: ______________________________) ..............

____

____ times

8

6. Does this farm keep records of the following information:
†1 Yes

a. Vaccinations?..........................................................................

b. Morbidity (illness)? .........................................................................................

†3 No

†4 Not given

†1 Yes

†3 No

Mortality?..............................................................

†1 Yes, daily

†2 Yes, not daily

†3 No

d. Feed consumption?..............................................

†1 Yes, daily

†2 Yes, not daily

†3 No

e. Egg production? ...................................................

†1 Yes, daily

†2 Yes, not daily

†3 No

a. Live on-site?...................................................................................................

†1 Yes

†3 No

b. Work at another commercial poultry production or processing facility? ......

†1 Yes

†3 No

c.

Section E. People
1. Does the producer or do any other employees:

2. What is the primary language spoken by the:
a. Producer?......................................

†1 English

†2 Spanish †3 Other (specify: ____________)

b. Employees? ..................................

†1 English

†2 Spanish †3 Other (specify: ____________)

3. Does this farm:
a. Have written biosecurity protocols? ...............................................................

†1 Yes

†3 No

b. Conduct formal employee biosecurity training?.............................................

†1 Yes

†3 No

4. Did any of the following types of people visit this farm during the
previous 12 months?
Col 1

If Col 1 = YES, did visitor
enter poultry housing?

a. Federal/State veterinarian
or animal health worker

†1 Yes

†3 No

†1 Yes

†3 No

b. Extension agent or university veterinarian

†1 Yes

†3 No

†1 Yes

†3 No

c.

†1 Yes

†3 No

†1 Yes

†3 No

d. Company service person

†1 Yes

†3 No

†1 Yes

†3 No

e. Nutritionist or feed company consultant

†1 Yes

†3 No

†1 Yes

†3 No

f.

†1 Yes

†3 No

†1 Yes

†3 No

g. Vaccination crew

†1 Yes

†3 No

†1 Yes

†3 No

h. Customer (private individual)

†1 Yes

†3 No

†1 Yes

†3 No

i.

Wholesaler, buyer, or dealer

†1 Yes

†3 No

†1 Yes

†3 No

j.

Renderer

†1 Yes

†3 No

†1 Yes

†3 No

k.

Feed delivery personnel

†1 Yes

†3 No

†1 Yes

†3 No

l.

Other business visitors (including other
producers and service personnel)

†1 Yes

†3 No

†1 Yes

†3 No

†1 Yes

†3 No

†1 Yes

†3 No

Private or company veterinarian

Catch crew

m. Other nonbusiness visitors (including
neighbors, friends, and school field trips)

9

5. How often are visitors who enter the poultry houses
recorded in a visitor log? ..................................................

†1 Always

†2 Sometimes

†3 Never

6. Are the following measures always, sometimes, or never required for
producer/employees, catch/vaccination crews, and visitors who enter
the poultry housing area?
[If no catch or vaccination crews, leave column blank.]
Producer/
Employees
†1 Always
†2Sometimes
†3Never

Catch/
Vacc Crews
†1 Always
†2Sometimes
†3Never

b. Different personnel for
different houses

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

NA

c. Change of clothing
(disposable)

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

d. Change of clothing
(washable)

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

e. Change shoes or foot cover

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

f. Foot bath (liquid)

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

g. Foot bath (dry)

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

h. Scrub footwear (bucket and
brush)

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

i. Not be around other poultry
(at least 24 hours)

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

j. Cannot own poultry or birds

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

†1 Always
†2Sometimes
†3Never

a. Shower

Visitors
†1 Always
†2Sometimes
†3Never

7. Do the catch crews or vaccination crews catch birds for other companies?
a. Catch crews ............................................

†1 Yes

†3 No

†4 NA (no catch crews)

b. Vaccination crews ...................................

†1 Yes

†3 No

†4 NA (no vaccination crews)

10

Section F. Movement/Transport
1. Where are the replacement pullets for this farm raised? [Check one only.]
†1 On this farm
If on this farm, what is the distance from pullet house(s) to the nearest laying house?

_____ feet

†2 On a different farm site, same company (including contract)
†3 On a farm from another company
2. How many different farms supply pullets (or chicks if pullets
raised on farm) to this farm?.................................................................................

_____ farms

3. What is the average distance pullets (or chicks if pullets
raised on farm) are transported to the farm?........................................................

_____ miles

4. Which of the following best describes the vehicle most often used
to bring pullets/chicks onto this farm during the previous 12 months? [Check one only.]
†1 Vehicle dedicated to this farm only
†2 Vehicle dedicated to this company only
†3 Vehicle also used on other companys’ farms or independent farms
†4 Other (specify: ________________________________)
5. Which of the following best describes the procedures for placing
pullets in laying houses? [Check one only.]
†1 Whole farm all in/all out
[Include here if it takes a couple weeks to populate farm, but
birds are not introduced to an existing flock.]
†2 All in/all out by house
[Include here if it takes a couple weeks to fill barn, but
birds are not introduced to an existing flock.]
†3 Pullets added to existing flock(s)
†4 Other (specify: _____________________________)
6. Are males raised with pullets (and moved to the farm together), or raised
on a separate farm? [Check one only.]
†1 Males always raised on same farm as pullets
†2 Males always raised on different farm from pullets
†3 Males sometimes raised on same farm as pullets and sometimes on
different farm from pullets
7. During the previous 12 months, how many times did this operation introduce
spiking males to stimulate breeding activity? .......................................................

_____ times

[If Item 7 = 0, SKIP to Item 11.]

11

8. What was the source of spiking males?
a. Excess males from young flocks on same farm ............................................

†1 Yes

†3 No

b. Other farms, same company..........................................................................

†1 Yes

†3 No

c.

†1 Yes

†3 No

a. Routine testing of source farm for health status
(e.g., Mycoplasma or other tests) ..................................................................

†1 Yes

†3 No

b. Testing of males before placing on farm
(e.g., Mycoplasma or other tests) ..................................................................

†1 Yes

†3 No

c.

†1 Yes

†3 No

Other farms, different company .....................................................................

9. If spiking males came from other farms [Item 8b or 8c = Yes] which of
the following practices are in place?

Quarantine of males before introducing to laying flock..................................

10. If spiking males came from other farms [Item 8b or 8c = Yes] what was
the average distance spiking males were transported to the farm?

_____ miles

11. Which of the following best describes the vehicle most often used to remove
birds from this farm during the previous 12 months (e.g., transport birds
to slaughter or market)? [Check one only.]
†1 Vehicle is dedicated to this farm only
†2 Vehicle is dedicated to your company only
†3 Vehicle is also used on other company’s farms or independent farms
†4 Other (specify: ______________________________________)
12. How many times per week are eggs transported to the hatchery? .....................

_____times/week

13. What is the distance to the hatchery that hatches eggs from this farm? .............

_____ miles

14. Which of the following best describes the vehicle most often used to
transport eggs from this farm to the hatchery during the previous 12 months?
[Check one only.]
†1 Vehicle dedicated to this farm only
†2 Vehicle dedicated to this company only
†3 Vehicle also used on other companys’ farms or independent farms
†4 Other (specify: ______________________________)
15. Does the hatchery that hatches eggs from this farm also hatch eggs from:
a. Other farms within the same company? ........................................................

†1 Yes

†3 No

b. Other farms from different company? ............................................................

†1 Yes

†3 No

12

16. Which of the following best describes how flats are usually handled? [Check one only.]
†1 Disposable
†2 Returned to same farm
†3 May go to other farms, same company only
†4 May go to other farms, other companies
†5 No flats used
[If Item 16 = 1, SKIP to Item 18.]
[If Item 16 = 5, SKIP to Item 20.]
17. Are flats usually cleaned and disinfected before
leaving hatchery and returning to a farm? ...........................................................

†1 Yes

†3 No

18. Are buggies used to roll flats onto the trucks used at different premises? ..........

†1 Yes

†3 No

†1 Yes

†3 No

†1 Yes

†3 No

[If Item 18 = NO, SKIP to Item 20.]
19. Are buggies cleaned and disinfected between farms? ........................................
20. Which of the following best describes how racks are usually handled?
[Check one only.]
†1 Returned to same farm
†2 May go to other farms, same company only
†3 May go to other farms, other companies
†4 No racks used
[If Item 20 = 4, SKIP to Item 22.]
21. Are racks usually cleaned and disinfected before leaving
hatchery and returning to a farm? .......................................................................
22. Which of the following best describes the vehicle most often used to
transport shavings to this farm during the previous 12 months? [Check one only.]
†1 Vehicle dedicated to this farm only
†2 Vehicle dedicated to this company only
†3 Vehicle also used on other companys’ farms or independent farms
†4 Other (specify: ______________________________)
23. During the previous 12 months, how often did this farm share any
outside tools, equipment, or machinery other than racks and flats
(e.g., tractors, feeding equipment, litter spreaders, trailers) with:
[Exclude equipment for cleanout or bird movement in/out.]
a. Another farm, same company? ................. †1 At least monthly

†2 Less than monthly

†3 Never

b. Another farm, different company? ........... †1 At least monthly

†2 Less than monthly

†3 Never

[If both Items 23a and 23b = NEVER, SKIP to Section G.]

13

24. Is shared equipment/machinery washed and disinfected
before being brought onto the farm? ..................................................................

†1 Yes

†3 No

Section G. Area Information
†1 West

1. In which region is this farm located (see map)?

†2 Central

†3 East

Poultry 2010 Regions
WA
MT
ME

ID

ND

MN

OR
WI
VT NH

SD

WY

MI
CA

MA

NY

CT

NV

IA

NE

UT

RI

PA

IL
IN

OH

NJ

CO

MD
MO

DE

WV

KS

VA
KY

AZ
NM

NC
TX

OK
AR

TN

MS

AL

GA

SC

LA

FL

West
Central
East

2. Enter code for density of poultry in this farm’s county:.........................................
(See supplemental form for a list of counties and corresponding density codes.)
†1 1 = < 0.25 birds per square mile

_____ code

†2 2 = 0.25 to 1 birds per square mile
†3 3 = 1 to 100 birds per square mile
†4 4 = 100 to 2000 birds per square mile
†5 5 = more than 2000 birds per square mile
3. What is the approximate distance (in either feet or miles) from this farm to the nearest:
a. Water body where wild water fowl congregate? ..................

_____ feet

OR _____ miles

b. Premises with commercial poultry that contracts
with this company?...............................................................

_____ feet

OR _____ miles

c.

Premises with commercial poultry, different company?.......

_____ feet

OR _____ miles

d. Premises with backyard/hobby/fighting poultry?..................

_____ feet

OR _____ miles

e. Live poultry market/poultry flea market? ..............................

_____ feet

OR _____ miles

f.

_____ feet

OR _____ miles

Processing/rendering facility ................................................

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4. Approximately how many of the following types of premises
are within a 1-mile radius of this farm?
a. Commercial poultry farm that contracts with this company? .........................

_____ premises

b. Commercial poultry farm, different company? ...............................................

_____ premises

c.

Backyard/hobby/fighting poultry?...................................................................

_____ premises

d. Premises with pigs? .......................................................................................

_____ premises

5. Have you seen free-ranging backyard poultry within 100 feet of this farm
in the last 12 months? ........................................................................................

†1 Yes

†3 No

6. What is the shortest distance from any of the poultry houses to the nearest:
a. Road?

.........................................................................................................

_____ feet

b. Farmland on which litter or manure is spread?..............................................

_____ feet

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