U.S. Department of Agriculture

AGRICULTURAL MARKETING SERVICE

FEDERAL GRAIN INSPECTION SERVICE

QUESTIONNAIRE FOR PROPOSED

DIVERTER-TYPE MECHANICAL SAMPLER

FORM APPROVED OMB NO. 0581-0309

According to the Paperwork Reduction Act of 1995, an agency may 

not conduct or sponsor, and a person is not required to respond 

to a collection of information unless it displays a valid OMB control 

number. The valid OMB control number for this information 

collection is 0581-0309. The time required to complete this 

information collection is estimated to average 1 hour per response, 

including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing 

and reviewing the collection of information.

Facility Name, City, State

Field Office

Kind of Elevator Capacity

Authorization - Select All that Apply

 Diverter Non-diverter Probe All Grains Small Grains Coarse Grains - Not Corn

 In Out Cargo Barges Hopper Cars Carlots Trucks

D/T Make and Model S/N

Spout Belt

Spout / Belt Size

General Location Spout / Belt Name Spout / Belt Angle Belt Speed

Power:

Air Electric

Body Dimensions Pelican Stroke Pelican Opening L x W

Grain Drop Before Sampler (ft) Grain Drop After Sampler (ft) Access Safe

Yes No

Inspection Door OK?

Yes No

Verified No Auxilliary Controls 

Yes No

Location of Lockout OK?

Yes No

Lights OK for Exams?

Yes No

Is Pelican Movement Steady?

Yes No

Does Pressure Return Promptly?

Yes No

Air Pressure at Rest PSI

Timer Make and Model Grain Flow Rate Past Sampler Calculated Timer Setting 

seconds

Secondary Make and Model S/N Delivery System

Gravity Pneumatic

Grams per Sample

Total No. of Samples Quantity Adjustment Sealed?

Yes No

Delivery & Collection Box Secure?

Yes No

Excess Returned to Lot?

Yes No

Dust Control Locations

Weights:

GIPSA Class X GIPSA Class Y Certified Other

Number of Shipping Bins: Depth (ft) Graded

 Before or After Release

Procedures to Stop Breakage:

Carrier I.D. by:

Radio Visual Other

Remarks/special restrictions when used to sample officially:

Signature of Official Personnel: Date:

FORM FGIS-998 (01/24) Previous editions are obsolete. Expires 03-25
U.S. Department of Agriculture

AGRICULTURAL MARKETING SERVICE

FEDERAL GRAIN INSPECTION SERVICE

QUESTIONNAIRE FOR PROPOSED

DIVERTER-TYPE MECHANICAL SAMPLER

FORM APPROVED OMB NO. 0581-0309

According to the Paperwork Reduction Act of 1995, an agency may 

not conduct or sponsor, and a person is not required to respond 

to a collection of information unless it displays a valid OMB control 

number. The valid OMB control number for this information 

collection is 0581-0309. The time required to complete this 

information collection is estimated to average 1 hour per response, 

including the time for reviewing instructions, searching existing data 

sources, gathering and maintaining the data needed, and completing 

and reviewing the collection of information.

Facility Name, City, State

Field Office

Kind of Elevator Capacity

Authorization - Select All that Apply

 Diverter Non-diverter Probe All Grains Small Grains Coarse Grains - Not Corn

 In Out Cargo Barges Hopper Cars Carlots Trucks

D/T Make and Model S/N

Spout Belt

Spout / Belt Size

General Location Spout / Belt Name Spout / Belt Angle Belt Speed

Power:

Air Electric

Body Dimensions Pelican Stroke Pelican Opening L x W

Grain Drop Before Sampler (ft) Grain Drop After Sampler (ft) Access Safe

 Yes No

Inspection Door OK?

 Yes No

Verified No Auxilliary Controls 

 Yes No

Location of Lockout OK?

 Yes No

Lights OK for Exams?

 Yes No

Is Pelican Movement Steady?

 Yes No

Does Pressure Return Promptly?

 Yes No

Air Pressure at Rest PSI

Timer Make and Model Grain Flow Rate Past Sampler Calculated Timer Setting 

seconds

Secondary Make and Model S/N Delivery System

Gravity Pneumatic

Grams per Sample

Total No. of Samples Quantity Adjustment Sealed?

 Yes No

Delivery & Collection Box Secure?

 Yes No

Excess Returned to Lot?

 Yes No

Dust Control Locations

Weights:

GIPSA Class X GIPSA Class Y Certified Other

Number of Shipping Bins: Depth (ft) Graded

 Before or After Release

Procedures to Stop Breakage:

Carrier I.D. by:

Radio Visual Other

Remarks/special restrictions when used to sample officially:

Signature of Official Personnel: Date:

FORM FGIS-998 (01/24) Previous editions are obsolete. Expires 03-25

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Instructions for Completing Questopmmaire

1. Facility name, city, and state.

2. Name of FGIS field office.

3. Check the box indicating kind of elevator.

4. Storage capacity of elevator.

5. Authorization Code-circle the numbers that apply to the intended sampler use.

6. Sampler Make & Model; e.g., Gamet 6800S.

7. Sampler Serial Number.

8. Is the sampler in a spout or on a belt end? For spout samplers-diameter or length x width cross sectional measurements or;

9. Belt Size-width and depth of grain carried.

10. General location of sampler; e.g., Headhouse 6th Floor; or Gallery.

11. Spout/belt name; e.g., Scale #1 lower garner.

12. Spout angle-90_ is vertical. Belt Angle-0_ is horizontal. Show normal angle and max/min limits of travel, if angle can be varied.

13. Belt speed-measure with belt loaded.

14. Check the box showing type of power.

15. Body dimensions for the sampler.

16. Pelican stroke is the distance traveled from one side to the other.

17. Length and width of the pelican opening.

18. Distance in feet from release point.

19. Distance grain falls is used to estimate impact and breakage. For example, measure from sampler to bin bottom.

20. Is access to the sampler by approved ladder or stairs, and does the platform have an approved railing?

21. Are the inspection doors properly located on the sampler? Do they have appropriate seal hasps and hinges?

22. Check verified after you determine that the system controls have no bypasses, dump counters, timer interrupts, or

programmable controllers.

23. Location of lockout ok-does the lockout provided meet FGIS requirements?

24. Light for examinations-can all exterior examination checks be made with lighting supplied?

25. For pneumatic/hydraulic samplers-is pressure sufficient to move the pelican across the stream of grain evenly, without lagging or

slowing down.

26. For pneumatic/hydraulic samplers-pressure returns to maximum before next cut is initiated.

27. For pneumatic samplers-gauge pressure at rest. Maximum reached when no cuts are initiated.

28. Timer Make & Model; e.g., Eagle HP5 Model 9.

29. Flow past sampler should be figured out by timing a known amount, such as one scale draft, as it passes the sampler.

30. Calculate the timer setting in seconds based on grain flow rate past sampler. Also show whether this is based on a 200, 350, or

500 bushel sampling rate.

31. Secondary Sampler (divider) Make & Model; e.g., InterSystems MD300.

32. Secondary Sampler Serial Number.

33. Check box indicating type of sample delivery system.

34. Weight in grams received for the official sample.

35. Total number of samples needed for all interested parties.

36. Are the quantity adjustment features on secondary sampler fixed or sealed in place?

37. Is the sample delivery system secure from the air inlet to the collection box?

38. Is excess grain automatically returned from the secondary to the lot from which the sample was taken?

39. Location of dust collection ducts-are they located where they can affect the sample constituents? The measurements will serve

as a record of approved duct work.

40. Weights-are weights official; i.e., supervised under the USGSA as Class X or Y-are weights Certified; i.e., supervised unofficially

by a local organization-or are weights unofficial and not supervised, or not provided?

41. Shipping bins-number used.

42. Shipping bin depth(s).

43. Grading-will bin be held for grade or factor results before being released?

44. Procedures to stop breakage-will the bins require use of cushion level indicators, grain ladders, or baffles to reduce impact of

grain and resulting breakage?

45. Carrier identification or stowage locations.

46. Special restrictions-any special procedural restrictions; e.g., weighback belt must be sealed, turnhead must be locked in

position, cushion must be maintained in shipping bin, etc.

47. Name or signature of the official personnel who filled out the questionnaire.

48. Date information obtained.