Form OF-301a VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES

OMB 0596-0080 v1

VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES
VOLUNTEER AGREEMENT TYPE (Choose 1) Individual OR Group					2. NAME OF GROUP (if applicable)
NAME OF VOLUNTEER OR GROUP LEADER COMPLETING FORM (Last, First)					U.S. CITIZEN OR PERMANENT RESIDENT Yes, I am a U.S. citizen or Permanent Resident No, I am not a US Citizen or Permanent Resident (if applicable, list visa type___________________________)
STREET ADDRESS, APT #	CITY				STATE			ZIP CODE
DATE OF BIRTH	PHONE				EMAIL ADDRESS
DEMOGRAPHIC INFORMATION (Optional): Please indicate both ethnicity and race and tell us if you are a veteran or have a disability. Multiracial respondents may select two or more races. This information will inform our understanding of diversity and inclusion among the volunteer force in the natural and cultural resource areas.
12a. Ethnicity (Select one): Hispanic, Latino, or Spanish Origin Not Hispanic, Latino, or Spanish Origin	12b. Race (Select one or more, regardless of ethnicity): American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or Other Pacific Islander					12c. Are you a Military Veteran or Active Duty Military? Yes No
						12d. Do you have a disability? Yes No
EMERGENCY CONTACT INFORMATION
NAME (Last, First)			PHONE		EMAIL ADDRESS
STREET ADDRESS, APT #			CITY		STATE			ZIP CODE
GOVERNMENT OFFICIAL COMPLETES THIS SECTION
NAME OF AGENCY/ BUREAU				AGREEMENT #
AGENCY CONTACT NAME (Last, First)				AGENCY CONTACT EMAIL & PHONE
REIMBURSEMENTS APPROVED: Yes No Type and Rate of Reimbursement:				VOLUNTEER POSITION/GROUP PROJECT TITLE:
26. Description of service to be performed. Provide a brief abstract of volunteer or service activity and the location of the volunteer activity, and attach description of service to be performed. Service description should include details such as time and schedule commitment, use of government vehicle, use of personal equipment and/or vehicle, skills required (note certifications if necessary), level of physical activity required, etc. VOLUNTEER/SERVICE ACTIVITY ABSTRACT 27. Check all that apply: Description of service attached OF-301b Volunteer Sign-up Form for Groups attached Risk Assessment attached Valid Driver’s License required Background Investigation required Medical Clearance Required Other:
PARENTAL CONENT FOR VOLUNTEER UNDER AGE 18
NAME			PHONE		EMAIL ADDRESS
STREET ADDRESS, APT #			CITY		STATE				ZIP CODE
I affirm that I am the parent/guardian of the abovenamed volunteer. I understand that the agency volunteer program does not provide compensation, except as otherwise provided by law; and that the service will not confer on the volunteer the status of a Federal employee. I have read the attached description of the service that the volunteer will perform. I give my permission for _________________________________________________ to participate in the specified volunteer activity. (NAME OF YOUTH)
							
Parent/Guardian Signature							Date
VOLUNTEER & GROUP LEADER AFFIRMATION
I understand that I will not receive any compensation for the above service and that volunteers are NOT considered Federal employees except as otherwise provided by law. I understand that volunteer service is not creditable for leave accrual or any other employee benefits. I also understand that either the government or I may cancel this agreement at any time by notifying the other party. I understand that my volunteer position may require a reference check, background investigation, and/or a criminal history inquiry in order for me to perform my duties. I understand that all publications, films, slides, videos, artistic or similar endeavors, resulting from my volunteer services as specifically stated in the attached job description, will become the property of the United States, and as such, will be in the public domain and not subject to copyright laws. I understand the health and physical condition requirements for doing the work as described in the job description and at the project location. I know of no medical condition or physical limitation that may adversely affect my (or members of the group’s) ability to provide this service. (If a group, see attached OF-301b) I consent to being photographed and to the release of my photographic image. (If a group, see attached OF-301b) I do hereby volunteer my services as described above, to assist in authorized activities at ________________________________________ and I agree to follow all applicable safety guidelines. See attached OF301b attached if a member of a group. (NAME OF FEDERAL AGENCY)
Signature of Volunteer or Group Leader							Date
The abovenamed agency agrees, while this arrangement is in effect, to provide such materials, equipment, and facilities that are available and needed to perform the service described above, and to consider you as a Federal employee only for the purposes of tort claims, liability and injury compensation to the extent not covered by your volunteer group, if any.
Signature of Government Representative							Date
TERMINATION OF AGREEMENT
Agreement Terminated Date:		Total Hours Completed:
Signature of Government Representative:
PUBLIC BURDEN STATEMENT
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 0596-0080. 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 U.S. Department of the Interior (USDOI), U.S. Department of Agriculture (USDA), U.S. Department of Defense (USDOD), and U.S. Department of Commerce (USDOC) are equal opportunity providers and employers and prohibit discrimination in all programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means of communication of program information should contact the volunteer program to which they are applying. If you would like to file a Section 508-related complaint, please contact the DOI Section 508 Program via email at [email protected] or phone (202) 208-1530.
PRIVACY ACT STATEMENT
Collection and use are covered by Privacy Act System of Records DOI-05 and OPM/GOVT-1 and are consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The information is used to identify persons interested in participating in a government volunteer program and to manage the volunteer program, including tort claims and injury compensation. Furnishing this information is voluntary, however, failure to provide the requested information will prevent program participation.

Volunteer Service Agreement OF301a USDA-USDI-DOC-DOD