Form 6045B Volunteer / Intern Emergency Medical Consent

OMB control no. 3095-0060 • expires 01/31/2013

VOLUNTEER / INTERN
Emergency Medical Consent form
Name of volunteer
This form is filed in your volunteer or intern personnel record. The National Archives will contact the persons you list in case of an emergency and arrange to
transport you to the nearest medical facility.
EMERG ENCY C ONTACT IN F ORM AT ION
Please list two individuals whom we can contact in case of a medical emergency.
Name
Street address
City/State/Zip
Home Phone

Work

Cell

Work

Cell

Name
Street address
City/State/Zip
Home Phone

EMERG ENCY T RE ATMEN T
In emergencies requiring immediate medical attention, you will be taken to the nearest hospital emergency room. Your signature authorizes the National Archives to have you transported to that hospital.
volunteer / intern signature

date

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
25 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 (I), 8601 Adelphi Road, College Park, Maryland 20740.
PRIVACY ACT STATEMENT
Collection of this information is authorized by 44 U.S.C. 2104 and 44 U.S.C. 2105(d). The information you provide to NARA on
this form will be used to determine if you will be accepted as a volunteer. This information may be disclosed to an expert, consultant, agent or contractor of NARA to the extent necessary for them to assist NARA in the performance of its duties or in accordance
with any other “routine uses of records” listing in the Privacy Act System of Records NARA 26, “Volunteer Files.” Completing this
form is voluntary, but failure to provide all of the requested information will result in you not being accepted as a volunteer.

National archives and records administration • na form 6045B (11-12)

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