FSMA - Farm Inventory

Farm Information Survey

Food Safety Modernization Act (FSMA) - Produce Safety Rule
Farm Name:*
Personnel Completing Farm Survey:*

Farm RepresentativeTDA Outreach SpecialistOther
Farm Contact Personnel:*

First NameLast Name
E-mail Address:
Phone Number:*
Format: (000) 000-0000.
Farm Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Texas County farm is located in:
Farm Mailing Address (if different from physical address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any other states that your operation is located in:
Food Safety or Other Point of Contact Information
Check one:

This is the same person as listed above.We do not currently have a person listed in this position.My Farm has a Food Safety point person.
POC Firm/Facility Name:
POC Name:

First NameLast Name
POC Phone Number:
Format: (000) 000-0000.
POC Email:
example@example.com
Farm Information
Does your Farm (check all that apply):*

grow produceharvest producepack producehold produce
Annual Average Sales (in the previous 3 years):*

Less than $25KVery Small ($25K - $250K)Small ($250K - $500K)Large (Over $500K)Not Available
Select the crop(s) that you produce:*
Does your farm participate in a 3rd Party Audit?

YesNo
Is your produce intended for commercial processing that adequately reduces pathogens (for example, commercial processing with a “kill step”)?

YesNo
Does your farming operation use soil amendments of animal origin? (ex. Manure)*

YesNo
Is your produce for personal/on-farm consumption?

YesNo
Water sources used:*

Ground WaterSurface WaterWellPondCanalAquiferRain Water CollectionCity/Rural Water DistrictsOther
Is there a map of your water distribution system?

YesNo
How is water applied?

DripOverheadSprayFloodFurrows
Website Address:
Should be Empty:

Farm Information Survey

Food Safety or Other Point of Contact Information

Farm Information