Food Safety Modernization Act (FSMA)
Produce Safety Rule Questionnaire
Pursuant to Arizona Revised Statutes (A.R.S.) 3-525.03
1688 West Adams St., Phoenix, Arizona 85007
agriculture.az.gov| Phone: 602-542-0439| Fax: 602-542-0898
Farm | Business Name_______________________________________Website__________________________
Farm | Bus. Address_________________________________________________________________________
City ______________________County___________________ State___________ Zip Code_______________
Mailing Address| P.O. Box____________________________________________________________________
City ______________________County___________________ State___________ Zip Code_______________
Food Safety Representative Information (Required):
Name _________________________________________
Email _________________________________________
Work Phone ________________Cell ________________
Alternate Representative Name:
Name _________________________________________
Email _________________________________________
Work Phone ________________Cell ________________
Average annual produce sales or income derived from
services rendered (e.g. harvesting services or
cooling/holding services)
Last 3-Year Average:
Less than $25K $250K – 500K
…...$25K – 250K Greater than $500K
All Produce Sales – Do you sell all your produce
directly to consumers, restaurants, grocery stores or
retail food establishments that are within 275 miles of
your farm or within the state of Arizona?
Yes No
Average Food Sales – During the previous 3 year
period, were your average food sales less than $500K?
(Food Sales mean the sale of produce, processed food,
hay, and commodities such as food grains, dairy and
livestock.)
Yes No
Covered Activities
Please check all that apply:
꙱ Grower ꙱ Packer ꙱ Holder/Cooler
꙱ Harvester ꙱ Grower-Shipper
Current Food Safety Program(s)
Please check all that apply:
꙱ GAP/GHP ꙱ GMP
꙱ LGMA ꙱ Harmonized
꙱ SQF ꙱ None
꙱Other Program ________________________
(Please Specify)
Crops grown, harvested, packed or held/cooled
Please check all that apply:
꙱ Vegetables ꙱ Melons ꙱ Citrus
꙱ Tree Fruit ꙱ Leafy Greens
꙱ Other Food ___________________________
(Please Specify)
What is your growing season or business season?
(e.g. planting date to harvest date)
Start Month_________ End Month __________
꙱ Year-round
Has someone from your company taken the PSA
Grower Training Course?
Yes No
Would you be interested in a free, voluntary
farm visit by AZDA staff to help ensure that
your farm is in compliance with the Produce
Safety Rule?
Yes No
