OF-new Volunteer Services Agreement for Natural Resources Agenc

OMB 0596-0080 (Expires 08/2010)

Volunteer Services Agreement for Natural Resources Agencies for Individuals or Groups
Please print when completing this form
Site Name      	Agency      		Reimbursement (if any)      
Name of Volunteer or Group Leader – Last, First, Middle      	Home Phone      	Cell Phone      	Email Address      
Street Address      	City      	State      	Zip      

IF VOLUNTEER IS UNDER AGE 18 – Name of Parent or Guardian      

Home Phone      

Cell Phone      

Email Address      

Street Address      

City      

State      

Zip      

I affirm that I am the parent/guardian of the above named volunteer. I understand that the agency volunteer program does not provide compensation, except as otherwise provided by law; and that the service will not confer on the volunteer the status of a Federal employee. I have read the attached description of the work that the volunteer will perform.

I give my permission for

     

to participate in the specified volunteer activity sponsored

by

     

at

     

(Name of Sponsoring Organization, if applicable)

(Name of Volunteer Duty Station)

From

     

to

     

     

(Date)

(Date)

(Parent/Guardian Signature)

(Date)

Emergency Contact Name      	Home Phone      	Cell Phone      	Email Address      
Street Address      	City      	State      	Zip      

GOVERNMENT OFFICIAL COMPLETES THIS SECTION
Brief description of work to be performed. Include details such as minimum time commitment required, use of personal equipment, use of government vehicle, etc. Attach the complete job description to this form. If this is a group agreement, the leader is to provide the group name, a complete list of group participants to be attached to this form, and parental approval (above) completed for each volunteer under the age of 18.      
Government Vehicle required?	Yes	No	Valid State Driver’s License	International Driver’s License
Personal Vehicle to be used?	Yes	No	Please verify that the volunteer is in possession of one of these documents. DO NOT keep a copy of the document for his/her file.

I understand that I will not receive any compensation for the above work and that volunteers are NOT considered Federal employees for any purpose other than tort claims and injury compensation. I understand that volunteer service is not creditable for leave accrual or any other employee benefits. I also understand that either the government or I may cancel this agreement at any time by notifying the other party. I understand that my volunteer position may require a background investigation in order for me to perform my duties. I understand that all publications, films, slides, videos, artistic or similar endeavors, resulting from my volunteer services as specifically stated in the attached job description, will become the property of the United States, and as such, will be in the public domain and not subject to copyright laws. I do hereby volunteer my services as described above, to assist in agency-authorized work.
			     
	(Signature of Volunteer)		(Date)
The above-named agency agrees, while this arrangement is in effect, to provide such materials, equipment, and facilities that are available and needed to perform the work described above, and to consider you as a Federal employee only for the purposes of tort claims and injury compensation.
			     
	(Signature of Volunteer Manager/Coordinator)		(Date)

Termination of Agreement
Volunteer requests formal evaluation		Yes	No			Evaluation Completed		     
								(Date)
Agreement terminated on	     
	(Date)			(Signature of Volunteer Manager/Coordinator)

Public 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) and U.S. Department of the Interior (USDI) prohibit discrimination in all 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 and USDI are equal opportunity providers and employers.

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 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 and USDI 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.

2 Optional Form New (06/2007)

USDA-USDI