FARM VERIFICATION QUESTIONNAIRE

Farm Name*
Farm Physical Street Address*
City*
State*
Zip Code*
Parish*
Farm Mailing Address: (if different from physical address)
Street Address
City
State
Zip Code
Parish
Full Name (Point of Contact)*

First NameLast Name
Phone Number*
"Enter Numbers Only"
Email Address*
example@example.com
Role on Farm (Check all that apply)*

OwnerFood Safety ManagerOperatorEmployeeOther (please describe)
If your farm has an alternate point of contact, please provide their information below.
Full Name (Alternate Contact)
Phone Number
"Enter Numbers Only"
Email Address
example@example.com
Role on Farm (Check all that apply)*

OwnerFood Safety ManagerOperatorEmployeeOther (please describe)
FARM PRODUCTION INFORMATION
On-Farm Activities (Please check all that apply)*

Grow ProduceHarvest ProducePack ProduceHold Produce
Average annual gross produce sales for the last three years: (Select only one)*

Less than $25,000$25,000 - $250,000$250,000 - $500,000More than $500,000
Do you sell the majority of your produce directly to consumers (Farmers' Markets, roadside stands), restaurants, or grocery stores that are within 275 miles of your farm or within the state of Louisiana?*

YesNo
During the previous 3 year period, were your average food sales less than $500,000? (Food sales include the sales of produce, processed food, hay, and commodities such as food grains, dairy and livestock.)*

YesNo
Does your farm use soil amendments of animal origin? (e.g., manure)*

YesNo
Type(s) of water sources used on farm (Select all that apply)*

Ground Water (Well Water)Surface Water (Pond Water)City/Rural water districts
Approximate Acreage (Select only one)*

0-1011-1516-2021-5051-100101-499500-9991000+
Typical Planting Period (Select all that apply)*

Already EstablishedYear RoundJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Typical Harvesting Period (Select all that apply)*

Year RoundJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Is your produce for personal/on-farm consumption?*

Yes, all of my produce is for personal consumptionSome, but not all of my produce is for personal consumptionNo, all of my produce is sold to others
Is your produce intended to be used in commercial processing? (i.e., canning, distilling, baking or some other action that includes a kill step)*

Yes, all of my produce will undergo some type of commercial processing that includes a “kill step”Yes, some of my produce will undergo some type of commercial processing that includes a "kill step"No, none of my produce will undergo some type ofcommercial processing thatincludes a “kill step”
Please place a (x) next to produce that your farm grows, harvests, packs or holds.*

ApplesApricotsApriumsAsian pearsAsparagusBabacosBasilBelgian endiveBlack beansBlackberriesBlueberriesBoysenberriesBrazil nutsBroad beansBroccoliBrussel sproutsBurdockCabbagesCantaloupesCarambolasCarrotsCashewsCauliflowerCeleriacCeleryChayote fruitCherriesChestnutsChickpeasChicory (roots and tops)Chinese cabbages (Bok Choy, mustard and Napa)ChivesCilantroCocoa beansCoffee beansCollardsCowpea beansCranberriesCucumbersCurly endiveCurrantsDandelion leavesDatesDill (seeds and weeds)EggplantsFigsFlorence FennelFood grains (such as barley, dent- or flint-corn, sorghum, oats, rice, rye, wheat, amaranth, quinoa, buckwheat, & oilseeds)Garden beets (roots and tops)Garden cressGarlicGenipGingerGlobe type antichokesGooseberriesGrapefruitGrapesGreat Northern beansGreen beansHazelnutsHoneydewHorseradishHuckleberriesJerusalem artichokesKaleKidney beansKohlrabiKumquatsLeekLemonsLentilsLettuceLima beansLimesMandarins (such as Clementines or Tangerines)MayhawsMelons (such as Canary, Crenshaw, and Persian)Microgreens (Varieties)MulberriesMuscadinesMushroomsMustard GreensNavy beansNectarinesOkraOnionsOrangesOreganoPapayaParsleyParsnipsPassion FruitPeachesPeanutsPearsPeasPecansPeppermintPeppers (such as bell and hot)PersimmonsPigeon peasPine nutsPinto beansPlumsPlumcotsPluotsPomegranatesPotatoesPumpkinsQuinceRadishesRaspberriesRhubarbRutabagasSageScallionsShallotsSnow peasSour cherriesSoursopSpinachSprouts (such as alfalfa and mung bean)StrawberriesSugar BeetsSummer squash (such as patty pan, yellow and zucchini)Sweet cornSweet potatoesSweetsopSwiss chardTangorsTaroThymeTomatoesTumericTurnips (roots and tops)WalnutsWater chestnutsWatercressWatermelonsWinter squashYams
Does your farm grow, harvest, pack, or hold any produce not included above? Please list below. Mark N/A, if not applicable.*

0/100
Should be Empty:

FARM PRODUCTION INFORMATION