USGS 9-2080 USDI-USGS Individual Volunteer Services Agreement

Form 9-2080 (June 1980) OMB 0596-0080 (Exp. 08/2010)

U.S. DEPARTMENT OF THE INTERIOR

U.S. Geological Survey

INDIVIDUAL VOLUNTEER SERVICES AGREEMENT

1a. Name of Volunteer (print or type)	1b. Social Security Number	1c. Date of Birth
1d. Address (include zip code)	1e. Home Telephone Number (include area code)
2a. Person to Notify in Emergency	2b. Relationship to Volunteer
2c. Address (include zip code)	2d. Telephone Number (include area code)

3. Agreement by Volunteer: I offer and agree to perform the services described below without compensation to assist the U.S. Geological Survey (USGS), in accord with the following understandings:

   1. I will contribute my services from       (date) to approximately       (date).

   2. This volunteer service will not confer on me the status of a Federal employee; however, while acting within the scope of this agreement, I am covered under the provisions of the:

1. Federal Tort Claims Act, which protects a Federal employee from liability for injury or damage to others while the employee is acting within the scope of he or her duties, and

2. Federal Employees Compensation Act, which authorizes compensation for work-related injury.

1. If I am less than 18 years old, my parent or guardian consents to this Agreement by signature below.

2. I understand the health and physical conditions requirements for performing the services described in item 4 below, and certify that I know of now physical condition or limitation that may adversely affect my ability to perform these services.

3. Either I or the USGS may terminate this Agreement at any time by notifying the other party in writing.

4. Because volunteers are not Federal employees, their volunteer service will not be creditable for leave accrual, retirement, or other benefit purposes if they later accept a Federal appointment.

   Signature of Volunteer			Date	     
   Signature of Parent or Guardian			Date	     
   	(If volunteer is under 18)

3. Project Description (attach an additional sheet as necessary)

USGS Project Supervisor	     			Title/Position			     
Division/Office/Location	     			Telephone			     
Organizational Code	     

5. Agreement by USGS: Under the authorities of Public Law 99-591, Public Law 100-202, and current Department of the Interior Appropriations Act, the USGS accepts this offer. While this Agreement is in effect:

a. The volunteer is covered by the provisions of the Federal Tort Claims Act and the Federal Employees Compensation Act.

b. The USGS will provide for such materials, supplies, equipment, support services, and facilities as are needed and are available to accomplish this project, except a may be specified in an attachment, marked:      .

Signature of USGS Official							Name (print or type)			     
Title/Position	     			Office/Location	     				Date		     

6. Time and Attendance: The volunteer must maintain a timesheet to ensure coverage in case of injury and to verify creditable experience for employment purposes.

7. Additional Information:

a. Volunteer Service (be specific)	     
b. USGS Retiree	 Yes	 No		SAVE	 Yes	 No
c. Scientist Emeritus	 Yes	 No
d. Faculty	 Yes	 No		School	     
e. Student	 Yes	 Yes		School	     

8. Termination of the Agreement: (At this time, volunteer will be provided information on how to obtain documentation, in the future, of their service)

	a. Total number of hours contributed by volunteer			     
	b. This Agreement was terminated on		     
Signature of USGS Official						Signature of Volunteer

PRIVACY ACT STATEMENT

The following information is provided to comply with the Privacy Act of 1974 (5 U.S.C. 552a): 5 U.S.C. 301 authorizes collection of information requested on this form, and Executive Order 9397 authorizes use of social security numbers to identify individual personnel records. The personal data will be used when emergency contact is necessary. Furnishing this information, including the social security, is voluntary, but failure to provide may result in nonacceptance as a volunteer.

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/USDI are equal opportunity providers and employesr.