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
0579-0477
EXP. Date 02/2027

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 The Privacy Act of 1974, 5 U.S.C 552a, which authorizes
acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the 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, 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 State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY).
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 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. 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, Mail Stop 9410, Washington, D.C. 20250-9410; (2)
fax: (202) 690-7442; or (3) email: [email protected].
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

DATE

Return completed form by email to [email protected]
MRP FORM 126C
APR 2025