Form OF 301A, Volunteer Services Agreement for Natural Resources Agencies

OMB 0596-0080 (Expires 8/2010)

Volunteer Services Agreement for Natural Resources Agencies
for Individuals or Groups

Please print when completing this form
Site Name

Agency

Name of Volunteer or Group Leader – Last, First, Middle

Home Phone

Cell Phone

Email Address

Street Address

City

State

Zip Code

Reimbursement (if any)

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

Home Phone

Cell Phone

Email Address

Street Address

City

State

Zip Code

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
by

to participate in the specified volunteer activity sponsored

(Name of Sponsoring Organization, if applicable)

From

at

(Name of Volunteer Duty Station)

to
(Date)

(Date)

(Parent/Guardian Signature)

(Date)

Emergency Contact Name

Home Phone

Cell Phone

Email Address

Street Address

City

State

Zip Code

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

Personal Vehicle to be used?

Yes

No

International Driver's License
Valid State Driver's License
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.

Optional Form 301A (6/2007)
USDA-USDI

OMB 0596-0080 (Expires 8/2010)

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
Agreement terminated on

(Date)

Yes

No

Evaluation Completed

(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.

Optional Form 301A (6/2007)
USDA-USDI