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
https://agriculture.az.gov/sites/default/files/AZDA%20Ag%20Questionaire%20%28003%29%20clean.pdf
2020
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 ________________________________________
Phone _________________ Cell ___________________
Alternate Representative Name____________________
Email ________________________________________
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
A
ll produce sales – Do you sell all your produce
directly to consumers, restaurants, 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 produce and food sales less
than $500K? (e.g. Fruits, vegetables, processed food,
hay, dairy, livestock and food grains)
⃝ Yes
No
Did your Produce sales exceed more than half of your
total Average Food Sales? (e.g. Food sales consists of
hay, dairy, livestock, processed food, and food grains)
Yes
⃝ No
Please check all that apply:
꙱ Harvester ꙱ Packer ꙱ Holder/Cooler
꙱ Grower ꙱ Grower - Shipper
Current Food Safety Program(s)
Please check all that apply:
꙱ GAP/GHP ꙱ GMP
꙱ LGMA…. ꙱ Harmonized
꙱ SQF.…… . ꙱ None
꙱ Other _______________________________
(Please Specify)
Crops grown, harvested, packed or held/cooled
Please check all that apply:
꙱ Vegetables ꙱ Melons ꙱ Citrus
꙱ Leafy Greens ꙱ Tree Fruit
꙱ Other Crops or 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
Name_____________________ Date____________
Location (City/State) _________________________
