Optional Form OF-301a (09/2010) OMB 0596-0080 (Expires 12/2013)
Volunteer Services Agreement for Natural Resources Agencies for Individuals or Groups
Please print when completing this form
Site Name/Project Leader	Agency U.S. Geological Survey	Reimbursement (if any)
Age (If Individual Agreement) Under18 18-25 26-55 56 and Older
Name of Volunteer or Group Leader - Last, First, Middle	Home Phone Mobile Phone Email Address
Street Address	City State Zip Code

IF VOLUNTEER IS UNDER 18 - Name of Parent or Guardian	Home Phone Mobile Phone Email Address
Street Address	City State Zip Code
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 work that the volunteer will perform. I give my permission for to participate in the specified volunteer activity sponsored by at (Name of Sponsoring Organization, if applicable) (Name of Volunteer Duty Station) From to (Date) (Date) (Parent/Guardian Signature) (Date)

Emergency Contact Name	Home Phone Mobile Phone Email Address
Street Address	City State Zip Code

GOVERNMENT OFFICIAL COMPLETES THIS SECTION
Brief description of work to be performed. Include details such as minimum time commitment required, use of personal equipment, use of government vehicle, etc. Attach the complete job description to this form. If this is a group agreement, the leader is to provide the group name, a complete list of group participants to be attached to this form, and parental approval (above) completed for each volunteer under the age of 18.
Government Vehicle required? YES NO	Valid State Driver's License International Driver's License
Personal Vehicle to be used? YES NO	Please verify that the volunteer is in possession of one of these documents. DO NOT keep a copy of the document for his/her file.

Optional Form OF-301a (09/2010)
I understand that I will not receive any compensation for the above work 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 background investigation 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 statement I have checked below is true: I know of no medical condition or physical limitation that may adversely affect my ability to provide this service. I do know of a medical condition or physical limitation that may adversely affect my ability to provide this service and have explained it to . I do hereby volunteer my services as described above, to assist in agency-authorized work. (Signature of Volunteer) (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 work described above, and to consider you as a Federal employee only for the purposes of tort claims and injury compensation. (Agreement will expire 2 years from this date) (Signature of Government Representative) (Date)

Termination of Agreement Volunteer requests formal evaluation YES NO Evaluation Completed (Date) Agreement Terminated on (Date) (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 OMS 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 US. Department of Agriculture (USDA) and US. Department of the Interior (USDI) 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. 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.

Optional Form OF-301a (09/2010)
Continuation Page:

Form OF-301A (6/2007)
ADDITIONAL INFORMATION FOR USGS REPORTING PURPOSES: Volunteer Name: Dates of service: FY FROM TO 2011 2012 2013 2014 2015 Date agreement was terminated: Volunteer Source: Volunteer Source (Be specific) USGS Retiree Yes No Scientist Emeritus Yes No Scientist Emeritus Honorary Yes No Faculty Yes No School: Elementary Junior High/Middle High College/University Student Yes No School: Elementary Junior High/Middle High College/University Volunteer Manager/Coordinator: Emerson Perez-Paniagua Hours Worked and Expenses Incurred: Total number of HOURS contributed by volunteer: FY Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 10/1 to 12/31 1/1 to 3/31 4/1 to 6/30 7/1 to 9/30 2011 2012 2013 2014 2015 GRAND TOTAL Total number of EXPENSES incurred by volunteer: FY Qtr 1 Qtr 2 Qtr 3 Qtr 4 Total 10/1 to 12/31 1/1 to 3/31 4/1 to 6/30 7/1 to 9/30 2011 2012 2013 2014 2015 GRAND TOTAL