6045B Volunteer / Intern Emergency and Medical Consent

OMB Control No.: 3095-0060

Expiration date: XX/XX/20XX

V OLUNTEER / INTERN EMERGENCY AND MEDICAL CONSENT

National Archives and Records Administration

This form is kept on file in your volunteer or intern personnel record. The information is essential for the [NARA facility] to contact the persons you designate in case of an emergency and to arrange to transport you to the nearest medical facility as warranted.

Emergency Contact Information: Please list two individuals whom we can contact in case of a medical or other emergency.

Name

Street Address

City State ZIP

Home Phone Work Phone Cell phone

Name

Street Address

City State ZIP

Home Phone Work Phone Cell phone

EMERGENCY TREATMENT: In emergencies requiring immediate medical attention, you will be taken to the nearest hospital emergency room. Your signature authorizes [NARA facility] to have you transported to that hospital.

__________________________________ _________________

Volunteer/Intern Signature Date

__________________________________

Printed Name

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Public burden reporting for this collection of information is estimated to be 6 minutes per response. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, Maryland 20740.

PRIVACY ACT STATEMENT

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information is authorized by 44 U.S.C. 2104. The information provided will be used to contact the referenced individuals in case of an emergency and to facilitate emergency treatment on your behalf. Furnishing this information is voluntary; however, failure to do so may prevent or delay us from taking immediate action in the event of a medical emergency.

NA 6045B (12-09)