OMB 0596-0080 (Expires 12/2013)
15. a. Which months would be available for volunteer work?
16. Specify at least three states or specific locations within a state where you would like to do volunteer work.
15b. How many hours per week would you be available for volunteer work? Hours
15c. Which days per week would you be available for volunteer work?
January
July
February
August
September
March
October
April
May
November
June
December
SaturdayFridayThursdayWednesdayTuesdayMonday Sunday
17. Specify your lodging needs:
Burden Statement
19. This is provided for more detailed responses. Please indicate the item numbers to which these responses apply:
18. If a volunteer assignment is not available at the location specified in Item 16, do you want your application forwarded to
another location or Federal agency seeking volunteers with your backgrounds/interests?
I will require assistance in finding lodging
I will furnish my own lodging (such as tent; camper; own, relative's, or friend's place)
No (Please specify)Yes
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 Agriculture (USDA) and U.S. Department of the Interior 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 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 and USDI are equal opportunity providers and employers.
Notice to Volunteer
Volunteers are not considered Federal employees for any purposes other than tort claims and injury compensation. Volunteer service is not
creditable for leave accrual or any other benefit. However, volunteer service is creditable work experience. By signing this application the volunteer(s)
understand(s) s/he may be subject to a reference check, background check, and/or criminal history inquiry.
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 for is
incomplete, enrollment in the program cannot proceed.
Privacy Act Statement
20. Signature (Sign in ink) 20. Date
Optional Form 301 (Rev. 6-08)
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