Coronavirus (COVID-19) Farmer Relief Assessment Form
RequiredRequired Question(s)
We would like to know the impact that the Coronavirus pandemic is having on your operation and how we can best respond to your needs.  Please take a moment to complete this survey and share with us. 

 
Required 1.
Name and Contact of Farmer/Farm Owner

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.

Business/Farm Name:

 

50 characters left.
3.

Location of Farm ( City, State, Zip, County) 


Leave blank if the same as address in previous question

 

50 characters left.
Required 4.
Are you a member of the Federation?
Yes
No
5.

 

 What is your race/ethnicity? (Optional)



Black/African American
Asian/Asian American
Latino/Hispanic
Multi-racial
White
American Indian
Would rather not say
Other  
6.

 What is your gender? (Optional)

Male
Female
Would rather not say
Other  
Required 7.
What was your gross farm revenue range for last year?
0-10,000
10,000-50,000
50,000-100,000
100,000-150,000
150,000 or more
Required 8.

Is farming your family's primary source of income?  Yes / No


 If not, estimate the percentage of income that comes from farming based on your farm income in the previous year.

Yes
No
  • Comment:

  • 500 characters left.
Required 9.
Please tell us more about your farm. Be sure to include the following: 
Number of acres in production
Crops grown
Number of Animals 
Number of Family Members 
Number of Employees 

 

350 characters left.
Required 10.

Are your markets affected COVID-19 ( such as farmers markets, schools, restaurants, etc.)?

Yes
No
  • Comment:

  • 500 characters left.
Required 11.
Briefly describe the impact the Coronavirus is having on your farm and family.
SELECT ALL THAT APPLY
Reduced markets to sell your products (restaurant sales down, farmers markets closing, etc.)
Reduced income due to loss of, or limited, off-farm work
Added healthcare costs
Lack of resource availability due to other business closures (e.g. seed companies, mechanics, delivery services, etc.)
Lack of ability to retain employees due to decreases in your business income
Inability to complete planned projects (infrastructure or otherwise) due to disrupted supply chains
Additional care-taking responsibilities that limit the time on your farm (i.e. childcare needs due to school closures, caretaking for other family members, etc.)
Other  
  • Comment:

  • 500 characters left.
Required 12.
What resources do you and farmers in your community most need?
SELECT ALL THAT APPLY
Direct financial assistance
Accounting/ business planning help
Food safety response planning assistance
Access to mental health care
Social/ digital media assistance for communicating with customers
Software and other technological support
Help connecting to others in your community
Help getting customers to purchase food you have for sale now
Other  
  • Comment:

  • 500 characters left.
Required 13.
What other resources would be helpful? 
SELECT ALL THAT APPLY 
Policy advocacy and support around this issues and related needs
Web-based community meetings to discuss shared challenges and solutions
A list of financial resources
Other  
  • Comment:

  • 500 characters left.
Required 14.
Have you applied for any available disaster aid?

If yes, please list
Yes
No
  • Comment:

  • 500 characters left.
Required 15.

Are you a member of a cooperative? 

Yes
No
16.

 If you answered yes to the previous question, how is COVID-19 impacting your cooperative?

 

50 characters left.
Required 17.

Are you seeking disaster relief funds due to COVID-19? 

Yes
No
18.

 

If you answered yes to the previous question, please provide your lead contact information for our disaster assistance program:


Please list their  ( Name, Title , Phone Number and Email Address ) in the text box below.


 

50 characters left.