Appendix B- Nomination Form -1

Appendix B OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Thank you for your interest in Produce Safety University. Please complete this online form no later than insert date to be considered for the insert year program. For more information about Produce Safety University visit: https://www.fns.usda.gov/ofs/produce-safety-university.

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 numbers for this information collection are 0584-XXXX. 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.

1. Name:
   
   

_____________________________ __________________________________

First Last

2. Work Email Address: ________________________________________________
   
   

3. Work Phone Number: _____-______-________
   
   

4. Job Title: ____________________________________________________________
   
   

5. Please provide your work address.
   
   

Street Address: ______________________________________________________

Address Line 2: ______________________________________________________

City: ___________________

State/Province/Region: ___________________

Postal/Zip Code: _____________

6. Select your organization type. (Check one)

• School district

• State agency

• Other
  
  

If school district is selected for Q6, show Q7, otherwise proceed to Q8.

7. How many students are enrolled in your school district? (Check one)

• Small (Less than 999)

• Medium (1,000 – 4,999 students)

• Large (5,000 - 24,999 students)

• Very large (more than 25,000 students)
  
  

8. Provide the name of your school district/State agency/other organization:
   
   _____________________________________
   
   

9. Does your organization participate in federally funded Child Nutrition programs?

• Yes

• No
  
  

10. How many years have you worked in Child Nutrition? (Check one)

• 0-5 years

• 6-10 years

• 11-15 years

• More than 15 years
  
  

11. Provide the name and contact information of the person who nominated you to attend Produce Safety University.
    
    

Name:

_____________________________ __________________________________

First Last

Work Email Address: ________________________________________________

Work Phone Number: _____-______-________

12. Have you previously attended Produce Safety University?

• Yes

• No
  
  

13. Select your top 3 training dates. All times are shown in Eastern time.

	Date and time	Date and time	Date and time	Date and time	Date and time
First choice	☐	☐	☐	☐	☐
Second choice	☐	☐	☐	☐	☐
Third choice	☐	☐	☐	☐	☐

No session preference. ☐

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