Form 590-2 NIH Special Volunteer Agreement

NIH Manual 2300-308-1, Appendix 3
Date: 11/23/11
Replaces: 8/16/11
Issuing Office: OD/OIR (301) 496-1921

OMB NO. 0925-0177
Expiration Date: February 28, 2021
NIH Special Volunteer Program

NIH Special Volunteer Agreement
I,
(name), offer to serve as a volunteer at the National Institutes of Health. In making
this offer, I understand and agree that I will:
1. Follow the supervision and direction of the NIH
employee(s) to whom I have been assigned to perform my
volunteer services and activities.
2. Agree to be bound by all provisions of Executive Order
10096, as amended, 45 C.F.R. Part 7 and any orders, rules,
regulations or the like issued thereunder, as if I were a
Government employee who conceived an invention or first
actually reduced it to practice while at the NIH. I agree to
disclose promptly to the appropriate NIH officials, all
inventions which I may conceive or first actually reduce to
practice during my visit to the NIH, and to sign and execute
all papers necessary for conveying to the Government the
rights to which it is entitled by virtue of Executive Order
10096, as amended, and this agreement.
3. Submit publications resulting from work at NIH to be
cleared for conformance with NIH publications policies.
4. Waive any and all claims for compensation from the
Government of the United States for any services
performed related to my volunteer assignment at NIH.
5. While on the premises of NIH, and while performing
volunteer services off the premises of NIH, conform to all
applicable administrative instructions and requirements of
the Department of Health and Human Services and NIH,
including all regulations and procedures concerning
conduct, safety, patient care, and animal care.
6. Be eligible under 5 U.S.C. 8101(1) (B) to file for benefits
for work-related injuries and /or illness that may arise and
are directly related to the performance of my volunteer
assignment.
7. May be eligible for coverage under the Federal Tort Claims
Act, (28 U.S.C. 2671 et seq.) and under section 224 of the
PHS Act for coverage from personal liability for damages
or injuries that arise from actions occurring within the
scope of my volunteer assignment and while under the
direct supervision of a federal employee. However, I
understand that the ultimate decision on issues of liability
and coverage depends on the circumstances of each
situation, and that the U. S. Department of Justice may
decline to represent me.

8. Not be considered to be an employee of the Federal
Government for any purposes other than tort claims and
injury compensation, and that my volunteer service is not
creditable for leave accrual or any other employee benefits.
9. If volunteering to provide direct patient care services, be
subject to the same requirements for obtaining clinical
privileges as other paid health professionals of the Public
Health Service.
10. Be responsible for any cost or treatment for any illness or
medical condition that may arise and is not directly related
to the performance of my volunteer assignment. I
understand that I must have or obtain adequate health
insurance coverage prior to the beginning of my volunteer
assignment until its conclusion, and that I must bear the
cost of such insurance myself. Furthermore, nonimmigrant foreign nationals sponsored as J-1 Exchange
Visitors must maintain adequate health insurance coverage
for themselves and any J-2 dependents as required by the
US Department of State.
I understand that my volunteer assignment will begin in
, and that I will
and end on
spend
hours/days per week providing volunteer services.
I also understand that my volunteer assignment may be
terminated at any time by either party to this agreement.
Please check this box if you will receive a salary or stipend
while at NIH that is derived in any way from, or related to,
Federal (including NIH) funds (e.g., grants, contracts, training
awards). Specify details on a separate page.
Public reporting burden for this collection of information is estimated to
average 5 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. An agency may not
conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to: NIH, Project
Clearance Office, 6701 Rockledge Drive, MSC7730, Bethesda, MD 20892 7730, ATTN: PRA (0925-0177). Do not return the completed form to this
address.

Signature of Volunteer

Date

Signature of Outside Employer Responsible Official

Date

Signature of Parent or Guardian of a Minor

Date

Signature of NIH Approving Official

Date

NIH 590-2 (02/18)