Arkansas Farm*A*Syst Survey and EQIP Confirmation Form

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**Arkansas FarmASyst**
Survey and EQIP Confirmation Form

Participant Signature:		Date :
County Agent Signature:		Date :

Thank you for participating in the Farmstead Assessment System Program. Your input and experience gained through this project will be very helpful in organizing farmstead assessment programs throughout the state. Participating in the Farm*A*Syst program can increase your credibility as a borrower with your banker and insurance provider as it indicates that you are doing your part to reduce environmental risk. In order to make improvements and provide quality information and assistance, we need to know about your experience with the program and any ideas you may have in regards to the program. Please take the time to answer the questions in this survey.

This also serves as a confirmation form for the EQIP applications. Your signature along with the signature of the county agent is required for this to be considered for credit in the EQIP application. The information obtained from this survey will be confidential and protected.

1. When was the farmstead assessment done on your farm? (mo/yr)

2. Please indicate whether each of the worksheets was beneficial, not beneficial or didn't apply to your farmstead by placing a check in the appropriate column.

3. Please put checks on the lines in the table to indicate how much attention you gave to the fact sheets and whether they were useful.

4. Please describe any changes that you have made or plan to make.

Changes planned:

Changes made:

5. If you have made any changes, please check the type of assistance that was needed to help you make those changes. (Check all that apply.)

no assistance needed
cost sharing
technical advice
engineering or design
information on management
other(specify)

6. If you don't plan to make changes in some high risk situations, please indicate why. (Check all that apply)

too busy
too expensive
don't believe it will make a difference
management changes are too time-consuming or impractical
need more information and/or assistance
other (specify)

7. On a scale of 1 to 10, with 1 being a waste of time and 10 being extremely useful, circle the number that most closely describes your feeling about completing the farmstead assessment and its usefulness for reducing contamination risks.

Waste of Time				OK			Extremely Useful
1	2	3	4	5	6	7	8	9	10

8. Do you have any comments on the farmstead assessment or suggestions on how it could be improved? (Attach another page if needed.)

University of Arkansas • Division of Agriculture
Cooperative Extension Service
2301 South University Avenue
Little Rock, Arkansas 72204 • USA
Phone (501) 671-2000 • Fax (501) 671-2209

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