Produce Safety University Nomination Form

UNITED STATES DEPARTMENT OF AGRICULTURE

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OMB Number: 0584-0611
Expiration Date: 09/30/2019

Food and Nutrition Service

APPENDIX B: NOMINATION FORM FOR 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 number for this information
collection is 0584-0611. The time required to complete this information collection is estimated to average fifteen 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. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition
Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0611). Do not
return the completed form to this address.
Nominees, please fill out this short form to complete your nomination to attend Produce Safety University.
1. Enter your name, contact information, and job title.
First Name:
Work Email Address:
2. In which State do you work?

Last Name:
Work Phone Number:

Job Title:

3. Provide Your Location Information.
City:

Zip Code:

4. In which USDA Region are you located?
Mid-Atlantic (Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Puerto Rico, Virgin Islands, Virginia,
and West Virginia)
Midwest (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin)
Mountain Plains (Colorado, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, South Dakota, Utah, and Wyoming)
Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont)
Southeast (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee)
Southwest (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas)
Western (Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Nevada, Northern Mariana Islands, Oregon,
and Washington)
5. Select your organization type:
School District (if selected jump to 6)

State Agency (if selected jump to 7)

Other (if selected jump to 8)

6. Provide the Name of Your School District.
7. Provide the Name of Your State Agency.
8. Provide the Name of the Organization or Employer You Represent.

Form FNS-909 04-19) Previous Editions Obsolete

SBU

Electronic Form Version Designed in AEM 6.4 Version

9. Select your top 3 training dates. You are highly encouraged to select the training nearest you as your 1st choice as this will
facilitate regional networking, and reduce travel costs paid by USDA.
1st choice

Date TBD

2nd choice

3rd choice

Location TBD
Date TBD
Location TBD
Date TBD
Location TBD
Date TBD
Location TBD
Date TBD
Location TBD
10. Provide the name and contact information of the person who nominated you to attend Produce Safety University.
First Name:
Last Name:
Work Email Address:

Work Phone Number:

11. Have you attended Produce Safety University in the past?
Yes

No

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