Survey Request Form

NYS Dept. of Ag and Markets, Division of Milk Control

I wish to enroll in Quality Milk Production Services and have a herd survey done at the earliest convenience.

(Print this form and fill out as completely and legibly as possible. Upon completion, please send to :)

Quality Milk Production Services
240 Farrier Rd.
Ithaca, NY 14853

Name: _______________________________________ Address:________________________________________

Town, State and Zip Code: _____________________________________ County:_________________________


Phone(s):______________________________________________  Best Time to Call:______________________


Fax:___________________________________ Email:________________________________________________

Directions to Farm:____________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________
Number of Cows Milking: ____________ Milking Times: _____ to _____; _____ to _____; _____ to _____
Cows have Permanent ID: Y / N   Type of Barn: Tiestall / Stanchion / Freestall
Milking System: Bucket / Pipeline / Flat Barn Parlor / Parlor    Parlor Size: Double_________ No. of Units:______
Switch Cows: Y/N      Switch How Many: ___________  Time of Switch (at morning milking) ________________

Veterinarian:___________________________________  

Milk Inspector: ________________________________

Address:______________________________________   

Milk Plant/BTU: ________________________________

_____________________________________________   

Address:_____________________________________

Phone: ____________________ Fax:_______________   

Phone: ___________________ Fax:_______________

Nature of Problem: High Cell Counts __________  High Clinicals __________ High bacteria counts_____________

Other Problems:________________________________________________________________________________
DHIA or Other testing Service: Y / N    Herd Number _______________ Access Code:______________________
Survey Type: V / R          Somatic Cell Service: Y / N         Average Linear Score:________________________

Comments:____________________________________________________________________________________

_____________________________________________________________________________________________

Date:________________  Producer Signature:_______________________________________________________