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Phytophthora ramorum Nursery Questionnaire

*Site Name: *Date:

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*Activity Action:

Trace Back Investigation

Annual Survey 

Delimit Monitor 

Quarantine Inspection (90+ Days) 

------------------

Perimeter

Intrastate Interstate Production

------------------

*POC Name: _____________ _ POC Title:_____________

*Address:---------------------------------

*City:_______________ *State:______ *Zip Code: ______ _

*County Name:_____________

Latitude (Decimal Degree Coordinates): Longitude (Decimal Degree Coordinates):

*Website: No Yes:---------------

Version 1, March 13, 2024

*Required question

*Site Type:

*Site Phone Number: Site Fax Number:

Camellia Kalmia Laurus Leucothoe 

Pieris Rhododendron Syringa Viburnum

Other:

 ________________________

Mahonia

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[Nursery name, etc.]

Nursery Environmental Site Email:

Nursery/Establishment Type:

Broker

The majority of this questionnaire is about the nursery. The Date and Activity Action refer to activities occurring at the

nursery. Additional information related to the activities can be captured in the Core Date Excel or other data tool. 

Compliance Inspection Compliance Inspection 

Trace Forward Investigation

Wholesale

Retail-Single Site Retail-Big Box 

Note: Select Nursery if it's a nursery, residence, or any other establishment. Select Environmental if the site is not. 

Residential

Botanical Garden Other

Critical Control Point (No Samples Taken)

Inspector/Surveyor: ------------------

--------- ---------

*Host Plants Sold:

 ________________________

Trace Forward and Back

Treatment Other
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Phytophthora ramorum Survey Questionnaire

Yes No Yes No 

Yes No 

*Host Plants Received:

*Site Previously Positive: No 

*Host Plants Propagated:

*Site Ships Interstate:

*Host Plant Placement: On soil On Benches On Gravel 

*Planting Containers Sanitation: Recycled with Sanitation Recycled without Sanitation 

Other

*Planting Medium Used: Includes Recycled Potting Media Mixed on Site

*Irrigation Water Source: Holding Pond Ground Water/Bore Well Municipal Water 

Other_______________________________

Hand Watering Sprinkler Other

Yes No 

Good Poor Standing Water None 

Version 1, March 13, 2024

*Required question

Puddling

Is Irrigation Water Source Yes, with UV Yes, both Chlorine and UV

Treated?

------------------ No

------------

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Other

Yes

Other

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In Standing Water

*Water Runoff into Streams and Rivers? Yes No

Yes No

*Irrigation Method:

*Retention Pond on Site:

Yes, with Chlorine

Yes, Other:

---------------------

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*Retention Pond Treatment

*Site Drainage

*Drainage Description:
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Phytophthora ramorum Survey Questionnaire

Did nursery purchase any other plantsfrom this source? Yes No 

Were these plants purchased from a broker? Yes No 

If yes, provide the broker's information below and attach invoices: 

Have you noticed any other problems with plants on your property? Yes No 

Version 1, March 13, 2024

*Required question

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If yes, describe other problems:

What is the address of that location?

When were the plants purchased?

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*Proximity of Site to Hosts in Environment:

Immediate (Within 100 Ft.) Nearby (More than 100 Ft.) None Visible Unknown

Back to General Nursery Information:

--------------------------

--------------------------

When did they ship? ----------------------------

----------------------------

*Trace Information Yes-Trace Forward Yes-Trace Back No Don't know

NOTE: For next 7 questions below, please note if referring to Trace Forward (TF) or Trace Back (TB)

If yes, what types and varieties? ----------------------------

Site Comments:
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Phytophthora ramorum Survey Questionnaire

Did the plant material come in pots? Yes No 

If yes, where are the pots now? 

Do you use or partner with a landscape company? Yes No 

Version 1, March 13, 2024

*Required question

Have host plants been trimmed or pruned? Yes No 

Have you received plants from a different location? 

If yes, please provide shipping documents. 

Where are your cull piles, compost piles and waste/rubbish bins on this site?

Yes No 

Where does the growing media come from?

How do you disinfest your pruning equipment? 

How are the trimmings disposed of?

If yes, where and when were they moved? 

Have plants been moved to other locations? Yes No 

Do you have multiple site locations? Yes No 

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If yes, what is the contact information for that company? 

If residence, have you added mulch, potting soil, or topsoil to the yard recently? 

If yes, where did you getthis material?

Yes No 

Phytophthora ramorum Survey Questionnaire

Version 1, March 13, 2024

*Required question

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