Farm Biosecurity Visitor Questionnaire
Please complete this questionnaire before entering the farm to help protect animal and human health. Your responses support our biosecurity management.
Full Name
*
First Name
Last Name
Organization or Affiliation
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date and Time of Visit
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Purpose of Visit
*
Please Select
Delivery or Pick-up
Consultation/Advice
Maintenance/Repair
Inspection/Regulatory
Social Visit
Other
Areas to be Visited on the Farm
*
Animal Housing/Barns
Feed Storage
Equipment Shed
Office/Administration
Other
Have you visited any other farms or had contact with livestock/poultry in the past 14 days?
*
Yes
No
Are you currently experiencing any symptoms of illness (fever, cough, sore throat, diarrhea, etc.)?
*
No symptoms
Mild symptoms (specify below)
Significant symptoms (specify below)
If you answered 'Mild' or 'Significant symptoms', please specify your symptoms.
Vehicle Registration/License Plate
*
Type of Vehicle or Equipment Brought onto Farm
Please Select
Car/Van
Truck
Tractor/Ag Equipment
Other
Are you bringing any animals or animal products onto the farm?
*
No
Yes (specify below)
If yes, please specify animals or products being brought.
Submit Questionnaire
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