Verification Form

FSMA Produce Safety Verification Form

*Qualified exempt farms must annually review farm sales records, complete this form, and submit to ISDA for renewal consideration.

Name of Farm:

Business Phone:

Farm Business Address:

City:

State:

Zip Code:

County:

Farm Mailing Address:

Same as Business Address

City:

State:

Zip Code:

County:

Website: (if applicable)

Business Email:

Primary Contact:

Phone:

Email:

Additional Contact:

Phone:

Email:

1. What does your farm grow, harvest, pack, or hold?

Please check all that apply.

If not above or *, add crop or variety below:

If other, please explain:

4. Approximate volume of commodities:

<5,001 lbs.

5,001-10,000 lbs.

10,001 – 50,000 lbs.

50,001 – 100,000 lbs.

100,001 – 150,000 lbs.

150,000< lbs.

5. What month do you start and end the following activities?

Planting Start Month

Planting End Month

Harvesting Start Month

Harvesting End Month

Packing Start Month

Packing End Month

6. To all that apply, fill in the percentage of your food (all food or drink for people or animals) that is sold to retail, farmers markets, food stands, distributors, or other (please specify).

Retail:

Farm Stand:

Farmers Market:

Distributor:

CSA:

Other:

7. Irrigation Water Source(s):

Ground (Well)

Surface (Canal, Pond, etc.)

Public (Municipal)

Other

If other, please explain:

8. Have you attended a Produce Safety Alliance Grower Training?

Yes

9. Irrigation Method:

Drip

Sprinkler

Furrow

10. Is 100% of the produce on your farm produced for personal consumption on your farm?

Yes

11. Does your produce receive commercial processing (kill step – pasteurization, dehydrating, etc.) that adequately reduces the presence of microorganisms of public health significance? *If yes, you must obtain written assurance from the processor as outlined in §112.2(b)(2)(3) and apply for an exemption with ISDA.

Yes

12. Do you receive any 3rd party audits? (Ex: GAP, Harmonized GAP, etc.)

Yes

If yes, which audit?

13. Do you have a Food Safety Plan?

Yes

For questions 14 & 15, please see the "Average Annual Sales Worksheet" to assist with calculations.

*Monetary value is strictly used to determine the size of your operation as defined by the Produce Safety Rule.

14. Size of your operation based on the previous 3-year average of all produce sales.

<$25,000

Very Small ($25,000 - $250,000)

Small ($250,000 - $500,000)

Large ($500,000<)

15. Previous 3-year average of all food sales. (Food as defined in §112.3(c)(1): all food or drink for people or animals)

<$25,000

Very Small ($25,000 - $250,000)

Small ($250,000 - $500,000)

Large ($500,000<)

Additional Comments:

Signature

Title

Date