FS-5300-33 Information Statement and Application

FS-5300-33 (v04-2016)

OMB Control No. 0596-0170 (Exp. XX/XX/20XX)

USDA-FOREST SERVICE

LAW ENFORCEMENT AND INVESTIGATIONS

RIDE-ALONG PROGRAM

INFORMATION STATEMENT AND APPLICATION

Thank you for your interest in the USDA Forest Service Law Enforcement and Investigations (LEI) Ride-Along Program. The following guidelines have been established for this program.

You will not be allowed to participate if (1) you are under 16 years of age, (2) you have been convicted of a felony or offenses involving illegal drugs or violence, (3) you are the subject of a current restraining order or warrant, or (4) you are under investigation, in custody, or under indictment for a criminal offense by any agency. You will be asked for information protected by the Privacy Act that is necessary to verify with the FBI and State law enforcement databases that none of the above applies to you. Providing this information is voluntary, but should you choose not to provide this information, you may be denied participation in this program. It is necessary to verify this information in order to protect the safety of our officers and the integrity of the LEI Ride-Along program.

You are requested to be attired in a manner that will in no way reflect negatively upon you, the program, or the USDA-Forest Service. For your safety and convenience, you will need to wear clothing and footwear that are suitable for outdoor conditions. The following are examples of types of clothing that are not acceptable: hot pants, shorts, tennis shoes, sandals, cropped tops, and T-shirts. You will arrange your own transportation to and from the Forest Service facility where the accompanying officer/agent is headquartered.

You are encouraged to ask questions about LEI programs. However, do not in any way interfere with the officer/agent’s handling of a situation. You may ask questions about a specific assignment after it has been completed and you have left the scene. You may observe an event on your ride that could require you to appear in court as a witness. You must use the safety belts and other safety equipment in the law enforcement vehicle. Certain calls are inherently dangerous. Your officer/agent may respond to such a call after dropping you off at a safe location.

An assumption of risk, waiver of liability, and indemnity form is attached and must be executed by you and by one of your parents or your legal guardian if you are under the age of 21 prior to the ride-along. In signing this form, you are agreeing to assume all risk of death, personal injury, and property damage, to waive all claims against the United States for negligence, and to pay the cost of defending the United States in any lawsuit and to pay any damages incurred by the United States in any lawsuit, other than those caused by the negligence of the United States, arising in connection with your participation in the LEI Ride-Along Program.

APPLICANT INFORMATION

Full Name (including middle or maiden name)      	Other Names Used      
Date of Birth      	Social Security Number      
Home Address      	Home Telephone Number      
Place of Work and Work Address      	Work Telephone Number      
Dates Requested To Ride      	Hours Requested To Ride      
Forest and District Requested      	Officer Requested for Ride-Along      
Reason For Ride-Along Request      

AUTHORIZATION FOR RIDE-ALONG

I authorize the above-named applicant to participate in the LEI Ride-Along Program by riding with me in my Forest Service vehicle at the above dates, times, and location. I attest that the above-named applicant has passed a background check and meets program criteria.

_________________________________________________

Officer/Agent (sign and print name)

APPROVAL FOR RIDE-ALONG PARTICIPATION

The above-named applicant has been approved to participate in the LEI Ride-Along Program with the above-named officer/agent at the above dates, times, and location.

_________________________________________________

Supervisory Officer/Agent (sign and print name)

VERIFICATION OF PARTICIPATION

The above-named applicant participated in the Ride-Along program at the above dates, times, and location.

_________________________________________________

Authorizing Officer/Agent Verification (sign and print name)

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 0596-0170. The time required to complete this information collection is estimated to average 5.75 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, 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 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 (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service. The collection of this information is authorized by Privacy Act System of Records USDA/FS-33 – Law Enforcement and Investigation Records.

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