Form NF 57-03-11 NF 57-03-11 NOAA Volunteer Diver Service Agreement

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX
NOAA Form 57-03-11
(08-15) Page 1 of 2

U.S. DEPARTMENT OF COMMERCE NATIONAL
OCEANIC AND ATMORSPHERIC ADMINISTRATION

NOAA VOLUNTEER DIVER SERVICE AGREEMENT
1.

NAME OF AGENCY

2.

AGREEMENT NUMBER

3.

NAME OF VOLUNTEER (Last, First)

4.

U.S. CITIZEN OR PERMANENT RESIDENT
Yes
No, list visa type

5.

STREET ADDRESS

7.

EMAIL ADDRESS

6.

8.

PHONE

CITY, STATE, ZIP CODE

9.

Home

AGE

Mobile

18-39

40-49

50-59

60 and Older

ETHNICITY & RACE (Optional): Please report 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 among the volunteer force in the NOAA Diving Program.

10.

ETHNICITY

10a.

Hispanic or Latino

RACE
American Indian or Alaskan Native

Asian

Not Hispanic or Latino

Black or African American

White

10b.

Native Hawaiian or Other Pacific Islander

No

Yes

10c.

Are you a Veteran?

10d.

Do you have a disability?

Yes

No

EMERGENCY CONTACT INFORMATION
NAME (Last, First)

11.

12.

PHONE

Home

13.

EMAIL ADDRESS

16.

RELATIONSHIP TO VOLUNTEER

Mobile
14.

STREET ADDRESS

15.

CITY, STATE, ZIP CODE

GOVERNMENT OFFICIAL COMPLETES THIS SECTION
17.

AGENCY CONTACT NAME (Last, First)

18.

PHONE

19.

Office

EMAIL ADDRESS

Mobile
20.

REIMBURSEMENTS APPROVED?

Yes

No

Type and Rate of Reimbursement:

Description of service to be performed. Provide a brief description of volunteer activity and the location of the volunteer activity to be performed.
Description should include details such as time and schedule commitment, use of government vehicle, use of personal diving equipment and/or vehicle,
skilles required (include diving and safety certifications required), level of physical activity required, etc.

21.

22.

Check all that apply:

Additional description of service attached

Diving and safety certifications verified

Job Hazard Analysis

Driver's License verified (if required)

Rev 27 Aug 2015

U.S. DEPARTMENT OF COMMERCE NATIONAL
OCEANIC AND ATMORSPHERIC ADMINISTRATION

NOAA Form 57-03-11
(08-15) Page 2 of 2

VOLUNTEER AFFIRMATION
23. I understand that I will not receive any compensation for the above service and that volunteers are NOT considered Federal employees
for any purpose other than tort claims and injury compensation. 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, and certify that the statements I have checked below are true:

I know of no medical condition or physical limitation that may adversely affect my ability to provide this service.
I have a medical condition or physical limitation that may adversely affect my ability to provide this service and have informed the
Government Representative.
I do not consent to being photographed or to the release of my photographic image.
I do hereby volunteer my services as described above, to assist in authorized activities at
and I agree to follow all applicable safety guidelines.

24.

Signature of Volunteer

(NAME OF NOAA FACILITY)

Date

The above-named NOAA facility agrees, while this arrangement is in effect, to provide such materials, specialized 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 you, if any.

25.

Signature of Government Representative

Date

TERMINATION OF AGREEMENT
26.

26.

Agreement Terminated Date:

Total Hours Completed:

Signature of Government Representative

PUBLIC BURDEN STATEMENT
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information
collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved
OMB Control Number for this information collection is 0648-XXXX. Without this approval, we could not conduct this information collection. Public reporting for this
information collection is estimated to be approximately 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 information collection. All responses to this information collection are required to obtain benefits. Send
comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the NOAA Diving Center
Executive Officer, NOAA Diving Program, 7600 Sand Point Way NE, Building 8, Seattle, WA 98115, 206-526-6460.

PRIVACY ACT STATEMENT
Authority: The collection of this information is authorized under 29 CFR 1910, Subpart T, Commercial Diving Operations. Additional authorities include 29 U.S.C. 653, 655, 657;
40 U.S.C. 333; 33 U.S.C. 941; Secretary of Labor's Order No. 8-76 (41 FR 25059), 9-83 (48 FR 35736), 1-90 (55 FR 9033), 6-96 (62 FR 111), 3-2000 (65 FR 50017), 5-2002 (67 FR
65008), 5-2007 (72 FR 31160), or 4-2010 (75 FR 55355) as applicable, and 29 CFR 1911.
Purpose: NOAA is collecting this information to assess an individual’s medical fitness to dive, proficiency, and further training. Information will also be used to ensure diving
equipment is safe and well maintained and that all policies are being adhered to for safety reasons. Aggregate data is used for annual reports and other leadership documents.
Routine Uses: NOAA will use this information in the determination of an individual’s medical fitness to dive. Disclosure of this information is permitted under the Privacy Act of
1974 (5 U.S.C. Section 552a) to be shared among Department staff for work-related purposes. Disclosure of this information is also subject to all of the published routine uses as
identified in the Privacy Act System of Records Notice NOAA-10, NOAA Diving Program.
Disclosure: Furnishing this information is voluntary. However, the failure to provide complete and accurate information will exclude the individual from NOAA’s Diving
Program.