SC-237A Request for Audit Services (Business, farms)

FORM APPROVED BY OMB No. 0581-0125

		UNITED STATES DEPARTMENT OF AGRICULTURE Agricultural Marketing Service Specialty Crops Program					REQUEST FOR AUDIT SERVICES
(This is the only acceptable form for fax or electronic submission to USDA for audit requests) NOTE: Fill in all appropriate blocks. Requested services may be delayed because of incomplete information. Type of service requested must be selected below.
DATE OF REQUEST:					ANTICIPATED DATE OF AUDIT:
AUDITEE INFORMATION						FARM / FACILITY INFORMATION
Company Name:						Location:
Street Address:
City, State & Zip:						Total Acres / Total Sq Feet to be audited:
Phone Number:
Contact Person:
APPLICANT INFORMATION						COMMODITIES TO BE COVERED BY AUDIT (Please List)
Company Name
Phone Number:
Fax Number:
E-mail:
Contact Person:
TYPE OF AUDIT SERVICES REQUESTED (Please choose at least one)
□ Produce GAPs Harmonized Audit - Field Operations & Harvesting □ Produce GAPs Harmonized Audit - Field Operations & Harvesting w/ Global Markets Primary Production Addendum □ Produce GAPs Harmonized Audit - Post Harvest □ Produce GAPs Harmonized Audit – Post Harvest w/ Global Markets Primary Production Addendum □ Mushroom Specific GAP Audit (M-GAP) □ Tomato Audit Protocol - Open Field Production, Harvest & Field Packing □ Tomato Audit Protocol - Packinghouse □ Tomato Audit Protocol - Greenhouse □ Tomato Audit Protocol – Repacking and Distribution □ Leafy Greens Audit (LGMA) □ Identity Preservation Audit (IP)							□USDA Good Agricultural Practices and Good Handling Practices (GAP&GHP) Audit (choose scopes below) □ Part 1 – Farm Review □ Part 2 – Field Harvest & Field Packing Activities □ Part 3 – House Packing Facility □ Part 4 – Storage & Transportation □ Part 6 – Wholesale Distribution Center / Terminal Warehouse □ Part 7 – Preventative Food Defense Procedures □ Other:
ADDITIONAL REMARKS
Once a request has been received, a USDA representative will make contact within 48 hours of receipt to schedule the audit.
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 0581-0125. The time required to complete this information collection is estimated average 2 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.

SC-237A (rev. 06-2016)

OMB 0581-0125

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

2. fax: (202) 690-7442; or

3. email: [email protected].

USDA is an equal opportunity provider, employer, and lender.

SC-237A (rev. 06-2016)