Mrp 126c Volunteer Time And Attendance Record

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 0579-XXXX. The time required to complete this
information collection is estimated to average 0.25 hours 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.

OMB Approved
0579-XXXX
EXP. Date XX/XXXX

VOLUNTEER TIME AND
ATTENDANCE RECORD

UNITED STATES DEPARTMENT OF AGRICULTURE
MARKETING AND REGULATORY PROGRAMS
PRIVACY ACT STATEMENT:

Collection and use is covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions of 5 U.S.C. 552a (Privacy Act of 1974), which authorizes
acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of USDA for the purposes of tort claims and injury compensation. Furnishing this data
is voluntary; however, if this form is incomplete, enrollment in the program cannot proceed.

NON-DISCRIMINATION STATEMENT:

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 identify (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 language other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to file a Program Discrimination Complaint 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.
USDA is an equal opportunity provider, employer, and lender.

NAME OF VOLUNTEER
DATE

TIME IN

TIME OUT

TOTAL HOURS

LOCATION

TOTAL HOURS

SIGNATURE OF VOLUNTEER

DATE

TO BE COMPLETED BY PROGRAM OFFICIAL

SIGNATURE OF FEDERAL EMPLOYEE SUPERVISORY PROGRAM OFFICIAL

DISTRIBUTION
Upon completion of volunteer service, please forward this form to:
MRP Volunteer Service Program Coordinator
USDA, MRPBS, HRD, HR Policy
4700 River Road, Unit 21
Riverdale, Maryland 20737
MRP FORM 126C
AUG 2020

DATE