SELF CERTIFICATION: CIVIL RIGHTS TRAINING

SELF CERTIFICATION: CIVIL RIGHTS TRAINING
If you have not already done so, please review the training slides below prior to signing the self-certification of training.
I hereby certify that I have reviewed and understand the civil rights training as required by United States Department of Agriculture regulations relative to my duties as staff/volunteer for:
Select the program types that apply to you:

The Emergency Food Assistance Program (TEFAP) PantrySenior Food Box Program (CSFP) Sub-AgencySoup KitchenA charitable institution (non pantry, TEFAP Outlet)Food Bank Staff (TEFAP)Food Bank Staff (CSFP)
Date*

MonthDayYear
Date
County*
Full Name*
Agency Name - please include your agency's full name, including any program designations or specific locations, if applicable.*
Agency ID# - if known
Please select your role at the agency:*

Person In ChargeStaff or volunteer
Signature*

Clear
Email (to receive a copy of your training certification)
example@example.com
PRINT & RETAIN A COPY OF THIS SELF-CERTIFICATION FOR PRESENTATION WHEN REQUESTED DURING A FIELD STAFF MONITORING REVIEW
THANK YOU!
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