FSMA - Farm Inventory

Farm Information Survey

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

Farm Representative TDA Outreach Specialist Other
Farm Contact Personnel: *

First Name Last Name
E-mail Address:
Phone Number: *
Farm Physical Address: *

Street Address

Street Address Line 2

City State / Province

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

Street Address

Street Address Line 2

City State / 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 Name Last Name
POC Phone Number:
POC Email:
example@example.com
Farm Information
Does your Farm (check all that apply): *

grow produce harvest produce pack produce hold produce
Annual Average Sales (in the previous 3 years): *

Less than $25K Very 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?

Yes No
Is your produce intended for commercial processing that adequately reduces pathogens (for example, commercial processing with a “kill step”)?

Yes No
Does your farming operation use soil amendments of animal origin? (ex. Manure)

Yes No
Is your produce for personal/on-farm consumption?

Yes No
Water sources used:

Protected well Surface water City/Rural water districts
Website Address:
Should be Empty:

Farm Information Survey

Food Safety or Other Point of Contact Information

Farm Information