Form FS-6500-1 Foreign Travel Proposal

USDA - Forest Service

FS-6500-1 (09/2011) OMB 0596-0216 (Exp.11/2011)

FOREIGN TRAVEL PROPOSAL (Reference FSH 6509.33)

THIS FORM MUST BE COMPLETED ELECTRONICALLY

PART I – TYPE OF REQUEST

New	SES Travel
Amended	FS-International Programs (IP) Sponsored
Passport Issuance Only Complete Parts II and VII only	Time Sensitive Request – Less Than 60 Days Prior to Departure Provide Justification:      

PART II - IDENTIFYING UNIT

1. Fiscal Year

     

5. FS Employee Invitational Traveler

2. Location

6. Legal name, title & grade of traveler (LAST, FIRST, MIDDLE NAME)

3. Staff

     

Name

     

4. Deputy Area

Job Title

     

Grade

     

PART III – TRIP INFORMATION AND JUSTIFICATION

1. Destination (city and country)      		2. Departure Date      		3. Return Date      	4. Trip Duration       days
5.	Purpose fo Travel: Mission (Operational) Special Agency Mission Conference/Not Training Training
6.	Detailed purpose of travel (See instructions)		     
7.	How does this trip benefit the FS?		     
8.	Why is this travel critical to accomplish this fiscal year?		     
9.	What is the minimum number of days required to accomplish the mission?		     
10	How many days of annual leave will be taken in conjunction with this travel?       If more than 0, Is your Cost Comparison attached? Y es No

PART IV – TRIP ITINERARY (Please include additional sheet if needed)

Day	Date	1. City and Country	2. Planned Activities
Day 1	     	     	     
Day 2	     	     	     
Day 3	     	     	     
Day 4	     	     	     
Day 5	     	     	     
Day 6	     	     	     
Day 7	     	     	     
Day 8	     	     	     
Day 9	     	     	     
Day 10	     	     	     

PART V - ESTIMATED TRAVEL COSTS

	1. FS Funded	2. Other Federal	3. Non-Fede	l 4. FS-IP Sponsored	4a. FS-IP Point of Contact
Transportation	$0.00	$0.00	$0.00	$0.00	Name       Telephone Number      	9. Funding Source      
Per Diem	$0.00	$0.00	$0.00	$0.00		10. In-Kind - $     	11. Reimbursable Agreement
Miscellaneous	$0.00	$0.00	$0.00	$0.00	E-Mail      	12. In-Kind - $     	13. Reimbursable Agreement
Total Cost	$0.00	$0.00	$0.00	$0.00		Job Code:      
5. Job Code      	5a. Override Code      	6. Type of funding: Appropriated Reimbursable In-Kind Is Agreement in place? Yes No		7. Source of funding if #2, 3, 4 is selected:       8. Other information, if applicable:      

PART VI - SIGNATURES

TRAVELER:      

Date:      

APPROVING OFFICIAL :       Title:      

Date:      

Nat’l Ldrship Council Rep:      

Date:      

FS CHIEF:      

Date:      

PART VII –MANDATORY INFORMATION –

1. Do you have a security clearance? None Secret Top Secret

2. Passport information – Must be completed for ALL requests

   1. Do you have a valid OFFICIAL PASSPORT? No Yes – Passport Number       Expiration Date      

   2. Do you have a PERSONAL PASSPORT? No Yes – Passport Number       Expiration Date      

   3. Country of Citizenship      

3. Date of birth      

4. Place of birth (City, State, Country)      

5. Last four digits of Social Security Number      

Last 4 of SS# ONLY REQUIRED FOR FOREST SERVICE EMPLOYEES

6. Physical mailing address – Your passport will be mailed to this address

Office Name	     	Office Telephone	     
Street Address NO P.O. BOXES	     	Fax Number	     
	     	Cell Phone Number	     
City, State, Zip Code	     	E-Mail Address	     

PART VIII – IN COUNTRY AND CONTACT INFORMATION (Please include additional sheet if needed)

1. Do you require admittance to the U.S. Embassy or Consulate? No Yes – please provide information below:

Name of Contact	     
Title	     
Telephone Number	     
E-Mail Address	     

2. Additional points of contact

Day	Date	Hotel Name Address, Phone # and Confirmation #	In Country Point of Contact Name, Title, Phone Number
Day 1	     	     	     
Day 2	     	     	     
Day 3	     	     	     
Day 4	     	     	     
Day 5	     	     	     
Day 6	     	     	     
Day 7	     	     	     
Day 8	     	     	     
Day 9	     	     	     
Day 10	     	     	     

3. Emergency contact information – SHOULD BE AVAILABLE 24/7 (Do not list someone traveling with you here)

	Work (Usually Supervisor)	Personal
Name	     	     
Official Title/Relationship	     	     
Telephone Number – Home	     	     
Telephone Number – Work	     	     
Telephone Number – Cell	     	     

What e-mail address will you access while out of country?      

What cell phone number can you be reached while out of country?      

4. Additional information:

1. Do you require Embassy hotel assistance? No Yes

2. Do you require Emabassy airport assistance? No Yes

3. List all other personnel traveling with you on this trip:      

     

4. Other pertinent information:      

PRIVACY ACT STATEMENT

Executive Order 9397 authorizes the collection and use of Social Security Numbers and Public Law 107-71 authorizes the collection and use of Passport Numbers. Collection and use are covered under Privacy Act System of Records USDA/OP-1 (Personnel and Payroll System for USDA Employees) and are consistent with the provisions of 5 USC 552a (Privacy Act of 1974).

PURPOSE: To facilitate the timely issuance of foreign travel requests, including and not limited to: Release of official US government passport, Issuance of official US government passports; Renewal of official US government passports; and visas, if necessary.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM: Current and prior employees of USDA and applications who were not hired, as well as permittees, cooperators, and contractors

ROUTINE USE(S): This information will be matched with lists at other Federal agencies such as the State Department and USDA Foreign Agricultural Service (Department of State's designated USDA control point for all Official and Diplomatic passports) to ensure that you are listed as a Forest Service employee and for verification to your employment status. Information will be gathered on the Forest Service form FS-6500-1 and then transferred to the USDA form AD-121

DISCLOSURE: Voluntary; however, failure to furnish the information on this form may result in disapproval of your travel request or issuance of your passport.

BURDEN AND NONDISCRIMINATION STATEMENTS

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 0596-0216. The time required to complete this information collection is estimated to average 20 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, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (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 toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

INSTRUCTIONS

Please refer to the Foreign Travel Desk Guide for additional information

PART 1 – TYPE OF REQUEST

Check the applicable box

New – Check this box if this is the initial request

Amended – Check this box to amend a previously submitted 6500-1

Passport Issuance Only – Check this box to request a new passport – Complete ONLY Parts II and VII

SES Travel – Select this box if position is of the Senior Executive Service

Time Sensitive Request – Check this box if this request is being submitted less than 60 days in advance

FS-International Programs (IP) Sponsored – Check this box if this is fullfilling an International Program request for foreign assistance programs (such as USAID, Department of State, etc.)

PART II – IDENTIFYING UNIT & DESTINATION

1. Fiscal Year: Forest Service fiscal year runs from October 1 – September 30, enter fiscal year during which travel will occur

2. Location: Enter Region/Station/Area

3. Staff: This is for Washington Office (WO) employees only

4. Deputy Area: Please select the area covering employment, for example: National Forest System; Research & Development, etc. from the drop down menu.

5. Type of Traveler: Select FS Employee if the Forest Service is paying the traveler’s salary. Select Invitational Traveler for non-Forest Service employee, volunteer, or non-government employee

6. Legal Name of Traveler: Enter travelers LEGAL NAME as it appears on the passport in the LAST, FIRST, MIDDLE format. Do not use abbreviations or nicknames

PART III – TRIP JUSTIFICATION

1. Destination: Enter the country you are traveling to. Your complete itinerary must be entered in Part IV.

2. Departure Date: This is the actual date on which you are departing the U.S. This must be accurate as visas and country clearances are based on this information. DO NOT PAD.

3. Return Date: This is the actual date you are arriving back into the U.S. This must be accurate as visas and country clearances are based on this information. DO NOT PAD.

4. Trip Duration: Enter the total number of days on travel.

5. Purpose of Travel: Select the appropriate box. These are the same Purpose of Travel codes you will select in GovTrip.

Mission (Operational) is defined as travel to a particular site in order to perform operational or managerial duties. This also include travel to attend a meeting to discuss general agency operations, review status reports, or discuss topics of general interest.

Special Agency Mission is defined as travel to carry out a special agency mission and or perform a task outside of the agency’s normal course of day-to-day business activities that are unique or distinctive. These special missions are defined by the head of the agency (in International Programs – foreign assistance programs) and are not programmed in the agency annual funding. Examples include: security missions, emergency response and recovery

Conference/Not Training is defined as travel performed in connection with a pre-arranged meeting, retreat, convention, seminar, or symposium for consultation or exchange of information.

Training is defined as travel in conjunction with educational activities to become more proficient or qualified in one or more areas of responsibility.

6. Detailed Purpose of Travel: Provide strong, detailed descriptions, and justification statmeent that will allow for independent reviewers to determine the importance and priority for the proposed trip. Include the activity, purpose, relevance, and role of the traveler. Do not use acronyms and spell out organization names.

7. How does this trip benefit the FS?: Provide a strong and detailed justification statement which will allow for independent reviewers to determine the importance and priority for the proposed trip.

8. Why is this travel critical to accomplish this fiscal year? Provide a strong and detailed justification statement which will allow for independent reviewers to determine the importance and priority for completing the proposed trip this fiscal year.

9. What is the minimum number of days required to accomplish the mission?: Enter the number of days required to complete the purpose of travel.

10. How many days of annual leave will be taken in conjunction with this travel?: If more than 0, you must prepare a cost-comparison to prove your additional annual leave will not cost the Forest Service additional funds.

PART IV – TRIP ITINERARY

To be completed for each day of the trip and must inlcude ALL countries traveling to for the duration of the trip.

1. City and Country – Enter the City and Country for that particular day

2. Planned Activities – Provide detailed list of activities planned for the day

PART V – ESTIMATED TRAVEL COSTS

This portion of the form does not automatically sum the transportation, per diem, and miscellaneous costs. Please enter the TOTAL COST.

1. FS Funded: Check this box and enter the estimated costs to the Forest Service job code for this travel

2. Other Federal: Check this box and enter the estimated reimbursable costs in which the Forest Service will be reimbursed for this travel.

3. Non-Federal: Check this box and enter the estimated reimbursable costs in which the Forest Service will be reimbursed for this travel. Select In-Kind if some travel costs are paid directly by the source.

4. FS-IP Sponsored Check this box if this is a Forest Service-International Program directed trip.

4a. FS-IP Point of Contact: Priovide the name, telephone number and e-mail address of the Forest Service-International Program point of contact.

5. Job Code: Insert job code from unit sponsoring the travel or Washington Office International Programs

5a. Overide Code: Insert override code from unit sponsoring the travel or Washington Office International Programs

6. Type of Funding: Select REIMBURSABLE or IN-KIND. If selecting REIMBURSABLE, please indicate if the reimbursable agreement is in place.

7. Source of Funding if #2, 3, 4 is selected: Provide the source of funding; i.e., Department of Interior, Fedearl Emegency Management Agency, Universities, or other source. Do not use abbreviations or acronyms.

8. Other information, if applicable: This space can be used for additional notes.

PART VI – SIGNATURES

Electronic signatures or physically signed copies are accepted.

Traveler: Should be signed by the traveler going on official travel.

Approving Official: This is traveler’s immediate supervisor or delegated official. If the traveler is NOT an employee, this must be approved by the official at the duty station of the request.

Nat’l Ldrship Council Rep: Must be signed by Deputy Chiefs, Chief Financial Officer, Regional Foresters, Station Directors, Area Director, International Institute of Tropical Forestry Director, Director Forest Products Lab, Director of Communications, Director of Legislative Affairs, Director of International Programs, Director of Law Enforcement and Investigations

FS Chief: Forest Service Chief will review and sign if approved.

PART VII – MANDATORY INFORMATION – DO NOT LEAVE ANY BLANKS

1. Do you have a Security Clearance? Please indicate NONE; SECRET; TOP SECRET. International Travel Office checks Forest Service Security for both issue and expiration dates, if a clearance has been indicated.

2. Passport Information: Complete all required information

3. Date of Birth: Enter your date of birth XX/XX/XXXX

4. Place of Bith: Enter your city and state or country of birth

5. Last Four Digits of Social Security Number: This applies to Forest Service employees only

6. Physical Mailing Address – Complete all required information. This is where your passport will be mailed. No post office boxes allowed, street addresses only. Note: This information is MANDATORY; failure to furnish may result in request not being processed in a timely manner.

PART VIII – IN-COUNTRY AND CONTACT INFORMATION

1. Do you require admittance to U.S. Embassy or Consulate? Yes or No

This is used on your country clearance cable. Embassies need to know if you will need access.

2. Additional Point of Contacts

• Hotel name, Address, Phone number and Confirmation number where you will stay in each country listed in Part I, item 6. List here or on continuation sheet. Please also include dates of stay.

• Name, Title and Phone of contact IN EACH country listed in Part I, item 6 or on continuation sheet. DO NOT USE someone here in the U.S.

3. Emergency Contact Information: Please enter all information. These individuals will be contacted if an emergency arises while out of country.

1. What e-mail address will you access while out of country? Enter e-mail address you will access while out of country.

2. What cell phone number can you be reached while out of country? Enter cell phone number where you can be reached while out of country.

3. Additional information: Use this space to include:

   1. Do you require Embassy Hotel assistance? Check the appropriate Yes or No box

   2. Do you require Embassy Airport assistance? Check the appropriate Yes or No box

   3. List of all other personnel traveling with you or on this trip

   4. Enter any other pertinent information that you deem necessary