QID 035219 Vegetable Chemical Use Survey Chemical Applications Cons

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: nass@nass.usda.gov
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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.