Form 1 Assignment

Attachment 1

OMB No. 0925–0177
Approved for use through March 31, 2026
New
Renewal
Transfer
Termination, Date (mm/dd/yyyy):

Special Volunteer and
Guest Researcher Assignment

Use prescribed by NIH Manual 2300 308–1

Special Volunteer (Provide services to NIH)
Guest Researcher (Use NIH facilities for own
research purposes)

SECTION I‒REQUEST FOR SPECIAL VOLUNTEER/GUEST RESEARCHER APPROVAL
1. NAME OF SPECIAL VOLUNTEER OR GUEST RESEARCHER
(last name, first, and middle name)
5. MAILING ADDRESS

8. CURRENT PHONE NO.

2. SEX
Female
Male

6. CITIZENSHIP

9. CURRENT FAX NO.

3. STARTING DATE
(mm/dd/yyyy)

4. NOT TO EXCEED DATE
(mm/dd/yyyy)

7. COUNTRY OF LEGAL PERMANENT RESIDENCE

10. DATE OF BIRTH (mm/dd/yyyy)

11. CITY & COUNTRY OF BIRTH

12. EDUCATION (See instructions on page 3)

13. PRESENT EMPLOYER OR INSTITUTION (Name & Address)

14. PRESENT POSITION TITLE

15. HEALTH INSURANCE COVERAGE (See instructions on page 3)
17. AMOUNT OF SALARY OR STIPEND*

16. SOURCE OF SALARY OR STIPEND*
18. OUTSIDE SPONSOR (Name, organization and address)*

19. BRIEF DESCRIPTION OF THE WORK TO BE PERFORMED AND THE SPACE TO BE OCCUPIED (Any patient contact requires prior
approval through the NIH Clinical Center and any other clinical setting, as appropriate.)
For Special Volunteer or Guest Researcher, state general research area:

20. NAME AND ORGANIZATION OF SUPERVISOR (for Special Volunteer)
OR NIH HOST (for Guest Researcher)

20A. PHONE NO.

20B. SIGNATURE OF SUPERVISOR OR NIH HOST

20C. DATE (mm/dd/yyyy)

21. APPROVAL SIGNATURE (For Special Volunteer ‒ IC approving official.)
(For Guest Researcher ‒ IC Scientific Director) SIGNATURE REQUIRED.

22. DATE (mm/dd/yyyy)

* Items 16,17, and 18 must be completed for all Guest Researchers. Complete as applicable for Special Volunteers.
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SECTION II‒ARRIVAL INFORMATION
1. IC/LAB AND LOCATION (Building and room)

2. PHONE NO.

3. LOCAL ADDRESS OF SPECIAL VOLUNTEER OR GUEST RESEARCHER

4. LOCAL PHONE NO.

SECTION III‒FOR FOREIGN SPECIAL VOLUNTEER OR GUEST RESEARCHER ONLY
1. VISA ASSISTANCE (See Section III Instructions for DIS/ORS document requirements)
Provide J‒1 visa assistance. (Requires at least a Master’s degree or equivalent)
Individual will enter U.S. in
Date of entry into U.S. (mm/dd/yyyy)

status (e.g., B‒1, WB) or is currently in the U.S. in

status (e.g., J‒2, G‒4).

If the Special Volunteer or Guest Researcher was previously at the NIH, list IC and years at the NIH (e.g., 2008-2009).
IC

Dates

Attach copies of all immigration documents for applicant and dependents, e.g., Forms 1‒94, DS‒2019, I‒797, and pages of passport.
(Provide CAN to send documents by express mail)
2. SPECIAL VOLUNTEER MDs ONLY: Check one, complete information, and attach documents as requested. Guest Researchers are not
eligible for any level of patient contact. See Section III Instructions for patient contact.
No patient contact
Incidental patient contact (Attach: Four‒Point Memorandum & ECFMG certificate [copy])
No change in program ‒ Four‒Point Memorandum not required (renewals only)
3. DEPENDENT INFORMATION (Dependents = spouse & unmarried children under 21)
Dependents?
No
Yes ‒ See Section III instructions.

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FORM NIH 590 INSTRUCTIONS
Section I:
Request for Special Volunteer/Guest Researcher Approval (to be
initiated by the NIH Supervisor Host and approved before the Special
Volunteer’s or Guest Researcher’s arrival). Foreign nationals (i.e.,
non-U.S. citizens or permanent residents) must be approved by the
Division of International Services (DIS), ORS, before the assignment
may begin.

19.

Describe the services to be provided by the Special Volunteer
or the Guest Researcher’s project, and the space he/she will
occupy.

20.

List NIH Supervisor or Host by name and organization.

21.

List phone number of NIH Supervisor or Host.

1-2.

Self-explanatory.

3-4.

List anticipated starting and ending dates of assignment.

22-23. Self-explanatory. For Guest Researchers or Special Volunteers
not in intramural research programs, the Division Director
or other major organizational component head who reports
directly to the IC Director should sign Block 22.

5.

List mailing address, not the temporary, local one.

6-7.

If not a U.S. citizen, list citizenship and country of permanent
residence. (Attach proof if different from country of citizenship).

Section II:

8-11.

Self-explanatory.

12.

List degrees, institutions, and dates. (If requesting a J-1 visa,
include copies of all degrees and English translations.

13-14. List current position title or status (e.g., “student”), organization
or institution, and address.
15.

List health insurance coverage

16-17. List the organization paying the Guest Researcher’s salary or
stipend during the NIH stay. If self-supporting, so state and list
funds available for the period of the NIH stay. If requesting a
J-1 Visa, proof of funding must be provided in U.S. dollars, on
institutional letterhead, indicating start and end dates. Indicate
if funding source is a foreign government.
18.

List outside sponsor. If self-sponsored, so state.

1-2. List the NIH address and extension on which the Special
Volunteer or Guest Researcher can be contacted.
3-4. List the local address and phone number rather than the
permanent home address listed in Block 5 above.
Section III:
1. Self-explanatory.
(https://ors.od.nih.gov/pes/dis/AdministrativeStaff/Documents/
grvlrequestchecklist.pdf)
2. See DIS/ORS Technical Advisories on patient contact at:
https://ors.od.nih.gov/pes/dis/AdministrativeStaff/Pages/
FullPatientContact.aspx
3. Attach sheet with following information for each accompanying
dependent: Full name (family, first, middle); relationship; date (mm/
dd/yy), city, and country of birth; nationality. If already in the U.S.,
also provide: passport no., issuing country, expiration date. Note: If
dependents will travel separately, give approximate dates of arrival.

PRIVACY ACT STATEMENT
Pursuant to the Privacy Act of 1974, NIH provides the following
explanation. The information requested on this form is collected under
authority of:
•

42 U. S. C. 282(b)(10) and 42 U.S.C. 284(b)(1)(K). These sections
permit the NIH to accept voluntary services in support of a wide
variety of NIH activities.

•

42 U. S. C. 241(a)(2) as implemented by Section 9.2., Title 45 of
the Code of Federal Regulations. This section permits the NIH
to make research and study facilities available to the scientific
community, especially qualified academic scientists and engineers.

Neither these statutes nor implementing regulations require or
authorize NIH to impose penalties for failing to respond. Accordingly,
your providing the requested information is voluntary. The effect of
refusing to provide the information requested on this form will be a
decision not to accept the services you may offer as a volunteer, or to
deny you the use of NIH research and/or study facilities. The purpose

of the information requested is to determine whether you meet the
criteria to provide volunteer services to NIH or to use NIH facilities.
Routine Uses:
•

Information furnished may routinely be disclosed to: institutions
providing financial support;

•

U. S. Office of Personnel Management for program evaluation
purposes;

•

the U. S. State Department for matters regarding foreign visitors;

•

the General Accounting Office for fund disbursement
determinations;

•

the Department of Justice in the event of litigation;

•

a congressional office responding to an inquiry from the person to
whom the record pertains;

•

Federal agencies that are considering you for employment and
need to verify your status while at NIH.

BURDEN STATEMENT
Public reporting burden for this collection of information is estimated
to average 6 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. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless

NIH 590 (03/23)

it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to:
NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN PRA (0925-0177). Do not return the
completed form to this address.

Instructions Page

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