R6-FS-1800-7 (PNW- Agreement for Individual Voluntary Services (Revised)

USDA Forest Service R6-FS-1800-7 (6/2007) PNW-94

OMB 0596-0080 (Exp. 08/2010)

AGREEMENT FOR INDIVIDUAL VOLUNTARY SERVICES

(Public Law 92-300, as amended)

1.

     

2.

     

Name (print Last, First, M.I.)

Social Security Number

3.

     

4.

     

Address (street, city, state, zip code)

Telephone Number

5.

Volunteer is: Local Non-local

6. Program Affiliation

     

7. Supervisor Name

     

Telephone #

     

Address

     

Optional

8.

Gender:

Male

Female

9.

Age:

Under 18

18-54

55+

10.

Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

11.

Race (Select one or more):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Position Description:      

GS Equivalent of this position:

     

Duty Station:

     

Place volunteer on travel authorization:

Yes

No

AD-202 #

     

Give IMB access to process travel documents:

Yes

No

The Forest Service agrees while this arrangement is in effect to:

1. Reimburse you for necessary incidental expenses, to the extent funds are available, and in accordance with Forest Service Travel Regulations, as follows:

   a.	Subsistence	Yes	No	(amount)	     		Remarks:	     
   b.	Transportation Allowance	Yes	No	(rate)	     		Remarks:	     
   c.	Provide Lodging	Yes	No	(rate)	     		Remarks:	     

2. Consider you as a Federal employee for the purpose of tort claims and compensation for work injuries.

3. Authorize you to operate Federal motor vehicles when necessary, provided you have a valid motor vehicle license/government operators I.D.

4. All of the above-described work will be noncompensable. Except as otherwise provided, I understand this service will not confer on me the status of a Federal employee.

5. I understand that either the Forest Service or I may cancel this agreement at any time by notifying the other party. I hereby volunteer my services as described above to assist the Forest Service in its authorized work.

6.			7.	     		8.	     
	Signature of Volunteer			DOB if under 18			Date
9.						10.	     
	Signature of Parent or Guardian, if under 18 years of age						Date
11.						12.	     
	Acceptance Signature, Forest Service Officer						Date

Emergency Notification Information

Name:	     		Relationship:	     
Address:	     		Telephone No:	     
Alternate:	     		Relationship:	     
Address:	     		Telephone No:	     
Physician:	     
Address:	     		Telephone No:	     

Termination of Agreement

1.	     		2.	     
	Date Agreement Terminated (month/day/year)			Signature of Forest Service Officer

Privacy Act Statement

Collection and use is covered by Privacy Act System of Records USDA/OP-1 and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the USDA Forest Service, Pacific Northwest Region, 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.

Burden Statement

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 0596-0080. The time required to complete this information collection is estimated to average 15 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

2

Routing: Original to Travel Clerk; Copy to Volunteer; Copy to Supervisor