Fillable Stelprd3826693 OMB Number 0596-0080 Optional Form 301a

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Stelprd3826693 OMB Number 0596-0080 Optional Form 301a

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  • 30 check-boxes
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OMB 0596-0080
VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES
1. INDIVIDUAL 2. GROUP
3.
NAME OF AGENCY
4.
AGREEMENT #
5.
NAME OF VOLUNTEER (First, Last)
6.
U.S. CITIZEN OR PERMANENT RESIDENT
Yes
No, list visa type_____________________________
7
. NAME OF GROUP
8
. NAME OF GROUP CONTACT (First, Last)
9.
STREET ADDRESS
10.
CITY, STATE, ZIP CODE
11.
EMAIL ADDRESS
12.
Home:
13.
AGE
Under 15 15 - 18 19 - 25
26 - 35 36 - 54 55 and Older
14.
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 and inclusion among the volunteer force in the natural and cultural resource areas.
14a.
Ethnicity (Select one):
Hispanic or Latino
Not Hispanic or Latino
14b.
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
14c.
Are you a Veteran? Yes No
14d.
Do you have disability? Yes No
EMERGENCY CONTACT INFORMATION
15.
NAME (Last, First)
16.
PHONE
Home:
Mobile:
17.
EMAIL ADDRESS
18.
STREET ADDRESS
19.
CITY, STATE, ZIP CODE
GOVERNMENT OFFICIAL COMPLETES THIS SECTION
20.
AGENCY CONTACT NAME (Last, First)
21.
AGENCY CONTACT EMAIL & PHONE
22.
REIMBURSEMENTS APPROVED: Yes No
Type and Rate of Reimbursement:
23.
VOLUNTEER POSITION/GROUP PROJECT TITLE:
24.
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. If this is a group
agreement, the leader is to provide the group name and attach a complete list of group participants or optional form 301b for each volunteer.
VOLUNTEER/SERVICE ACTIVITY ABSTRACT
25. Check all that apply: Description of service attached List of group participants/optional form 301b attached
Job Hazard Analysis Valid Driver’s License Verified (if required)
Volunteer Service Agreement OF301a USDA-USDI-DOC-DOD
OMB 0596-0080
PARENTAL CONSENT FOR VOLUNTEER UNDER AGE 18
26
. PARENT OR LEGAL GUARDIAN (First, Last)
27.
PHONE
Home:
Mobile:
28.
EMAIL ADDRESS
29.
STREET ADDRESS
30.
CITY, STATE, ZIP CODE
31.
I affirm that I am the parent/guardian of the above named 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)
32.
Parent/Guardian Signature
Date
VOLUNTEER & GROUP LEADER AFFIRMATION
33. 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 or group leader know of no medical condition or physical limitation that may adversely affect my or members of the group ability to provide this service. If a group
see attached OF301b.
I or a member of the group have a medical condition or physical limitation that may adversely affect my ability to provide this service and have informed the
Government Representative. If a member of a group see attached OF301b.
I or group member do not consent to being photographed or to the release of my photographic image. If a member of a group see attached OF301b.
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)
34.
Signature of Volunteer or Group Leader
Date
The above-named 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.
35.
Signature of Government Representative
Date
TERMINATION OF AGREEMENT
36. Agreement Terminated Date: Total Hours Completed:
37.
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.
Volunteer Service Agreement OF301a USDA-USDI-DOC-DOD
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Stelprd3826693 OMB Number 0596-0080 Optional Form 301a

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Completed 28 May 2020

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