GSA Optional Form 301A "Volunteer Service Agreement - Natural & Cultural Resources"

What Is GSA Optional Form 301A?

This is a legal form that was released by the U.S. General Services Administration on December 1, 2014 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2014;
  • The latest available edition released by the U.S. General Services Administration;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of GSA Optional Form 301A by clicking the link below or browse more documents and templates provided by the U.S. General Services Administration.

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Download GSA Optional Form 301A "Volunteer Service Agreement - Natural & Cultural Resources"

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OMB 0596-0080
VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES
INDIVIDUAL
GROUP
1.
2.
NAME OF AGENCY
AGREEMENT #
3.
4.
NAME OF VOLUNTEER (First, Last)
U.S. CITIZEN OR PERMANENT RESIDENT
5.
6.
Yes
No, list visa type_____________________________
. NAME OF GROUP
. NAME OF GROUP CONTACT (First, Last)
7
8
STREET ADDRESS
CITY, STATE, ZIP CODE
9.
10.
EMAIL ADDRESS
PHONE
AGE
11.
12.
13.
Home:
Under 15
15 - 18
19 - 25
Mobile:
26 - 35
36 - 54
55 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
14.
more races. This information will inform our understanding of diversity and inclusion among the volunteer force in the natural and cultural resource areas.
Ethnicity (Select one):
Race (Select one or more, regardless of ethnicity):
Are you a Veteran?
Yes
No
14a.
14b.
14c.
Hispanic or Latino
American Indian or Alaskan Native
Asian
Not Hispanic or Latino
Black or African American
White
Do you have disability?
Yes
No
14d.
Native Hawaiian or Other Pacific Islander
EMERGENCY CONTACT INFORMATION
NAME (Last, First)
PHONE
EMAIL ADDRESS
15.
16.
17.
Home:
Mobile:
STREET ADDRESS
CITY, STATE, ZIP CODE
18.
19.
GOVERNMENT OFFICIAL COMPLETES THIS SECTION
AGENCY CONTACT NAME (Last, First)
AGENCY CONTACT EMAIL & PHONE
20.
21.
REIMBURSEMENTS APPROVED:
Yes
No
VOLUNTEER POSITION/GROUP PROJECT TITLE:
22.
23.
Type and Rate of Reimbursement:
Description of service to be performed. Provide a brief abstract of volunteer or service activity and the location of the volunteer activity, and attach
24.
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
Check all that apply:
Description of service attached
List of group participants/optional form 301b attached
25.
Job Hazard Analysis
Valid Driver’s License Verified (if required)
Volunteer Service Agreement
OF301a
USDA-USDI-DOC-DOD
OMB 0596-0080
VOLUNTEER SERVICE AGREEMENT—NATURAL & CULTURAL RESOURCES
INDIVIDUAL
GROUP
1.
2.
NAME OF AGENCY
AGREEMENT #
3.
4.
NAME OF VOLUNTEER (First, Last)
U.S. CITIZEN OR PERMANENT RESIDENT
5.
6.
Yes
No, list visa type_____________________________
. NAME OF GROUP
. NAME OF GROUP CONTACT (First, Last)
7
8
STREET ADDRESS
CITY, STATE, ZIP CODE
9.
10.
EMAIL ADDRESS
PHONE
AGE
11.
12.
13.
Home:
Under 15
15 - 18
19 - 25
Mobile:
26 - 35
36 - 54
55 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
14.
more races. This information will inform our understanding of diversity and inclusion among the volunteer force in the natural and cultural resource areas.
Ethnicity (Select one):
Race (Select one or more, regardless of ethnicity):
Are you a Veteran?
Yes
No
14a.
14b.
14c.
Hispanic or Latino
American Indian or Alaskan Native
Asian
Not Hispanic or Latino
Black or African American
White
Do you have disability?
Yes
No
14d.
Native Hawaiian or Other Pacific Islander
EMERGENCY CONTACT INFORMATION
NAME (Last, First)
PHONE
EMAIL ADDRESS
15.
16.
17.
Home:
Mobile:
STREET ADDRESS
CITY, STATE, ZIP CODE
18.
19.
GOVERNMENT OFFICIAL COMPLETES THIS SECTION
AGENCY CONTACT NAME (Last, First)
AGENCY CONTACT EMAIL & PHONE
20.
21.
REIMBURSEMENTS APPROVED:
Yes
No
VOLUNTEER POSITION/GROUP PROJECT TITLE:
22.
23.
Type and Rate of Reimbursement:
Description of service to be performed. Provide a brief abstract of volunteer or service activity and the location of the volunteer activity, and attach
24.
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
Check all that apply:
Description of service attached
List of group participants/optional form 301b attached
25.
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
. PARENT OR LEGAL GUARDIAN (First, Last)
PHONE
EMAIL ADDRESS
26
27.
28.
Home:
Mobile:
STREET ADDRESS
CITY, STATE, ZIP CODE
29.
30.
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
31.
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)
Parent/Guardian Signature
Date
32.
VOLUNTEER & GROUP LEADER AFFIRMATION
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
33.
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
Signature of Volunteer or Group Leader
Date
34.
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.
Signature of Government Representative
Date
35.
TERMINATION OF AGREEMENT
Agreement Terminated Date:
Total Hours Completed:
36.
Signature of Government Representative:
37.
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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