Form AD-2022 Student Volunteer Service Agreement

Form Approved – OMB No. 0560-0232

OMB Expiration Date: 04/30/2021

AD-2022 U.S. DEPARTMENT OF AGRICULTURE (proposal 1) STUDENT VOLUNTEER PROGRAM SERVICE AGREEMENT
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended).  The authority for requesting the information identified on this form is 5 USC 3111.  The information will be used to set conditions and obtain agreement concerning the acceptance of student volunteers in a non-pay status for educationally-related work assignments.  The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for OPM/GOVT-1 - General Personnel Records.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility for the student volunteer to participate in this program.  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 0560-0232. 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO THE APPROPRIATE AGENCY.
Student Volunteer is an individual who is enrolled not less than half-time in high school, trade school, technical or vocational institute, junior college, college, university or other accredited educational institution who, with the permission of the institution at which enrolled, voluntarily performs services as part of an agency program established for providing educational experience.
1. Name of Student				2. Telephone Number (Including Area Code)
     				     
3. Home Address (Including Zip Code)
     
4. Name of Educational Institution
     
5A. Authorized Signature		5B. Title      			5C. Date      
6. Student’s Academic Status				7. Student’s Major
     				     
8. Enter a check for applicable Agency:			FAS	FSA		RMA
This Agreement is for the purpose of setting conditions for the acceptance of students in a nonpay status for educationally-related work assignments in compliance with the provision of 5 USC 3111.
The following conditions apply to this Agreement:
Participant must be a student who is enrolled not less than half-time at the institution.
Volunteer service is with the permission of the institution in which the student is enrolled.
Service under this Agreement will not be compensated by the Agency.
Volunteer service should be in accordance with appropriate Federal, State, and local regulations, regarding employment of minors.
Students will not be used to displace any employee.
Students are not considered to be Federal employees for any purpose other than the following: Compensation for injuries sustained during the performance of work assignments, in accordance with the provisions of 5 USC Chapter 81. b. Federal Tort Claims provisions of 28 USC 2671 through 2680. Compensation for injuries sustained during the performance of work assignments, in accordance with the Provisions of 5 USC Chapter 81. b. Federal Tort Claims provisions of 28 USC 2671 through 2680.
The Agency agrees to provide attendance and performance records to the institution as reasonably required in order for the experience to be properly credited.
The Institution agrees to refer the students without regard to race, creed, color, age, sex, physical handicap, or other non-merit factors.
The Agency agrees to endeavor to make the assignment beneficial to the academic aims of the student and the institution.

AD-2022 (proposal 1)						Page 2 of 2
9. I UNDERSTAND AND AGREE TO THE CONDITIONS OF MY SERVICE DESCRIBED ABOVE:
Student Signature				B. Date (MM-DD-YYYY)
				     
C. If under 18 years of age, Parent/Guardian Signature				D. Date (MM-DD-YYYY)
				     
10. TO BE COMPLETED BY RESPONSIBLE AGENCY OFFICIAL:
A. Location (Address)
     
B. Brief description of duties
     
C. Effective Date (MM-DD-YYYY)					D. Fiscal Year
     					     
11A. Selecting Official Signature					11B. Date (MM-DD-YYYY)
					     
12. TERMINATION OF AGREEMENT
A. Agreement Terminated On (Month, Day, Year )			B. Signature of Responsible Official	C. Signature of Volunteer/Student
     

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.