AD-2025 Revised Vounteer Attendence Record

This form is available electronically. Form Approved - OMB No. 0560-0232

AD-2025 (proposal 2)

U.S. DEPARTMENT OF AGRICULTURE Farm and Foreign Agriculture Service VOLUNTEER ATTENDANCE RECORD (Attendance Records must be maintained by the requesting office)

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended).  The authority for requesting the information identified on this form is 5 USC 3111 and 7 USC 2272.  The information will be used to record the attendance of student volunteers and volunteers.  The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for OPM/GOVT-1 - General Personnel Records.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility for the student volunteer or volunteer to participate in this program.  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 0560-0232. The time required to complete this information collection is estimated to average 15 minutes 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO THE APPROPRIATE AGENCY.

1. NAME OF VOLUNTEER (Please type or print last, first and middle name):

2. Month

3. Fiscal Year

     

     

    

A. DATE (MM-DD-YYYY)

B. ARRIVAL TIME

C. DEPARTURE TIME

D. NUMBER OF HOURS

E. LOCATION

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

     

     

     

  

     

F. Total Hours

   

4A. Volunteer Signature

4B. Date Signed (MM-DD-YYYY)      

AD-2025 (proposal 2) Page 2 of 2

5. To be completed by responsible Agency official:

A. Responsible official signature

B. Date Signed (MM-DD-YYYY)

     

C. Name of requesting office      

D. Check Applicable Agency: FSA FAS RMA

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’s income is derived from any public assistance program.  (Not all prohibited bases apply to all programs.)  Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).  To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay).  USDA is an equal opportunity provider and employer.