NF 57-03-11 NOAA Volunteer Diver Service Agreement

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

NOAA Form 57-03-11
(04-24) Page 1 of 2

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

10. ETHNICITY & RACE (Optional): Please report both ethnicity and race and tell us if you are a veteran or have a disability. This information will inform
our understanding of diversity among the volunteer force in the NOAA Diving Program.
10a.

What is your RACE and/or ETHNICITY? Select all that apply.
American Indian or Alaskan Native
Hispanic or Latino

Asian

Middle Eastern or North

Black or African American

White

African

Native Hawaiian or Other Pacific Islander

No

Yes

10b.

Are you a Veteran?

10c.

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)

NOAA Form 57-03-11
(04-24) Page 2 of 2

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

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
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. USDA, DOI, DOC and DOD 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.

PRIVACY ACT STATEMENT
Collection and use is covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions of 5 USC 552a (Privacy
Act of 1974), which authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of
the USDA and USDI for the purposes of tort claims and injury compensation. Furnishing this data is voluntary, however if this form is incomplete,
enrollment in the program cannot proceed.