Form 1 Agreement

Attachment 3

OMB No. 0925–0177
Expiration Date: March 31, 2026
NIH Manual 2300‒308‒1, Appendix 3
Date: 11/23/11
Replaces: 8/16/11
Issuing Office: OD/OIR (301) 496-1921

NIH Special Volunteer Program
NIH Special Volunteer Agreement

I,
this offer, I understand and agree that I will:

(name), offer to serve as a volunteer at the National Institutes of Health. In making

(1)

Follow the supervision and direction of the NIH employee(s)
to whom I have been assigned to perform my volunteer
services and activities.

(2)

Agree to be bound by all provisions of Executive Order
10096, as amended, 45 C.F.R. Part 7 and any orders,
rules, regulations or the like issued thereunder, as if I were
a Government employee who conceived an invention or
first actually reduced it to practice while at the NIH. I agree
to disclose promptly to the appropriate NIH officials, all
inventions which I may conceive or first actually reduce to
practice during my visit to the NIH, and to sign and execute
all papers necessary for conveying to the Government the
rights to which it is entitled by virtue of Executive Order
10096, as amended, and this agreement.

(3)

Submit publications resulting from work at NIH to be cleared
for conformance with NIH publications policies.

(4)

Waive any and all claims for compensation from the
Government of the United States for any services performed
related to my volunteer assignment at NIH.

(5)

While on the premises of NIH, and while performing
volunteer services off the premises of NIH, conform to all
applicable administrative instructions and requirements of
the Department of Health and Human Services and NIH,
including all regulations and procedures concerning conduct,
safety, patient care, and animal care.

(6)

Be eligible under 5 U.S.C. 8101(1) (B) to file for benefits
for work-related injuries and /or illness that may arise
and are directly related to the performance of my
volunteer assignment.

(7)

Very likely not be covered under the Federal Tort Claims
Act, (28 U.S.C. 2671 et seq.) or under section 224 of the
Public Health Service Act (42 U.S.C. 233 (a)) for damages
or injuries that arise from actions occurring within the scope
of my Federal volunteer assignment. The ultimate decision
on issues of coverage is made on a case-by-case basis by
the HHS Office of General Counsel, the US Department of
Justice, and, ultimately, the courts.

(8)

Not be considered to be an employee of the Federal
Government, and that my volunteer service is not
creditable for leave accrual or any other employee benefits.
Notwithstanding this, I may be eligible for compensation
for injuries sustained in the performance of my volunteer
duties, to the extent provided for by the Federal Employees
Compensation Act.

(9)

If volunteering to provide direct patient care services, be
subject to the same requirements for obtaining clinical
privileges as other paid health professionals of the Public
Health Service.

(10) Be responsible for any cost or treatment for any illness or
medical condition that may arise and is not directly related to
the performance of my volunteer assignment. I understand
that I must have or obtain adequate health insurance
coverage prior to the beginning of my volunteer assignment
until its conclusion, and that I must bear the cost of such
insurance myself. Furthermore, non-immigrant foreign
nationals sponsored as J-1 Exchange Visitors must maintain
adequate health insurance coverage for themselves and any
J-2 dependents as required by the US Department of State.

I understand that my volunteer assignment will begin in
and end on,
and that I will spend
hours/days
per week providing volunteer services. I also understand that my volunteer assignment may be terminated at any time by either party to
this agreement.
Please check this box if you will receive a salary or stipend while at NIH that is derived in any way from, or related to, Federal (including
NIH) funds (e.g., grants, contracts, training awards). Specify details on a separate page.
Public reporting burden for this collection of information is estimated to average 5 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
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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 Office, 6701 Rockledge Drive, MSC7730, Bethesda, MD 20892 7730, ATTN: PRA (0925-0177). Do not return the completed form to this address.
SIGNATURE OF VOLUNTEER

DATE

SIGNATURE OF OUTSIDE EMPLOYER RESPONSIBLE OFFICIAL

DATE

SIGNATURE OF PARENT OR GUARDIAN OF A MINOR

DATE

SIGNATURE OF NIH APPROVING OFFICIAL

DATE

NIH 590‒2 (03/23)

PSC Publishing Services (301) 443-6740

EF