Food Safety Education and Training Materials Sharing Form (Business Profit/Non Profit)

Food Safety Educational and Training Materials Submission Form

Contact Name: ___________________________________________________________

Contact Phone:___________________________________________________________

Contact Email:___________________________________________________________

Resource Title: ___________________________________________________________

Producer Name: ____________________________________________________

Producer Contact Information:

Street Address: _____________________________________________________

City/State/Zip: _____________________________________________________

Telephone: ________________________________________________________

Fax: _____________________________________________________________

Email: ___________________________________________________________

Year Published: ___________ Revision Date: __________ Edition: ____________

If this resource is available online, please provide the Web site address (url):

________________________________________________________________

Briefly, describe your resource:

What is the target audience(s)?

(To select more than one, hold down CTRL key while selecting):

What format(s) is the education material available?

(To select more than one, hold down CTRL key while selecting):

What topic(s), if any, describes the education material?

(To select more than one, hold down CTRL key while selecting):

Is it available in a Non-English Language(s)?

(To select more than one, hold down CTRL key while selecting):

What is the cost of the material (price/unit)? If item is “free” please specify.

_________________________________________________________

Can this material be ordered in quantity?

Yes___ No____

Describe any bulk discounts available:

Please indicate how this material may be used by other educators:

___ May copy for educational purposes without prior permission

___ Permission needed to copy

___ May not copy

How can this item be ordered or accessed?

Online (List url):______________

Printable Order Form (List url):__________________

By Phone: ____________

By Fax: _______________

Email: ________________

Free Download (List url):_____________________

Was this Education Material funded by a Grant?

Yes: ________ No __________

If yes, please specify:

Funding Agency:­­­­­­­­­­­­­_______________

Grant Number:_______________

Project Number:______________

Additional Comments or Information about this Education Material:

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to a collection of information unless it displays a valid OMB number. The valid OMB control number for this information collection is 0518-0046. The time required to complete this information is estimated at 19 minutes per response due to the averaging of check boxes and text fields.