Food Safety Mobile Questionnaire

Request a USDA Food Safety Mobile Visit

hrtp://www.fsis.usda.gov/Food_Safety_Education/request_a food_safe...

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Food Safety Mobile
Request a Food Safety Mobile Visit

FOr,..

This form may be submitted by persons who wish to request a
local visit from the USDA Food Safety Hobile.
Submission of this form is NOT a guarantee of availability and
does not commit USDA to attending the event.
¯ After you submit this form, a member of the FSIS Food
Safety Education Staff will contact you for further
information. Fields marked with an * ere required.
¯ If you are outside the continental United States, send an
email to foodsafetymobi]e@fsis.usda.gov rather than
submitting this form.
¯ Email questions to foodsafetymobile@fsis.usda.gov, or
call (301) 504-9605.

Food Safety Education
~- Be Food Safe
~ Food Safety Mobile
Is It Done Yet?

Organization*
Title
Address*
Address
City*
State*

1 Select a State

Zip*

Email Address*
Confirm Email Address*
Event Information
Star~ Date of Event
End Date of Event
Time of Event
Name of Event
Location of Event*

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Request a USDA Food Safety Mobile Visit

http://www.fsis.usda.gov/FoodSafetyEducation/request_a food safe...

Description of Event*

How Did You Hear About the
Mobile?

Comments ~ Questions

OMB Control Number. 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 ONB control number. The valid OMB control
number for this information collection is 0583-0133. The time
required to complete this information collection is estimated to
average 5 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.
Last Modified: March 14, 2009

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