Form 590 Special Volunteer and Guest Researchers

OMB No. 0925-0177
Approved for use through 7/31/05

Released 11/27/01. Please see instructions on Page 3.
New

Special Volunteer and
Guest Researcher Assignment

Renewal

Termination, Date:
Special Volunteer (Provide services to NIH)

Use prescribed by NIH Manual 2300 308-1

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 initial)

2. Sex

3. Starting Date

4. Not to Exceed Date

Female
Male

5. Mailing Address

8. Current Phone No.

9. Current Fax No.

6. Citizenship

7. Country of legal
permanent residence

10. Date of Birth
(MM/DD/YY)

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.)

*16. Source of Salary or Stipend

*17. Amount 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 of the NIH Medical Board.)
For foreign Special Volunteer or Guest Reseacher, state general research area

20. Name and Organization of Supervisor (for Special Volunteer) or NIH Host (for Guest Researcher)

21. Phone No.

22. Approval Signature (For Special Volunteer--IC approving official.)
(For Guest Researcher--IC Scientific Director)

23. Date

NIH 590 (Rev. 1/99)

Page 1 of 2 pages.

*Items 16, 17, and 18 must be completed for all Guest Researchers.
Complete as applicable for Special Volunteers.

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 (Attach C.V. & Bibliography, and copies of previous correspondence between sponsor and individual.)
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.

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

status (e.g., J-2, G-4).

.

Attach copies of all immigration documents for applicant and dependents, e.g., Forms I-94, IAP-66, I-797, and pages of passport.
(Provide CAN if you want FIC/ISB to send documents by express mail

)

2. MDs Only: Check one, complete information, and attach documents as requested. NIH-sponsored J-1 visa holders are limited to incidental 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.

NIH 590 (Rev. 1/99

Page 2 of 2 pages.

Form NIH 590 Instructions
Section I:

20.

List NIH Supervisor or Host by name and organization.

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).

21.

List phone number of NIH Supervisor or Host.

22-23. Self-explanatory. For Guest Researchers 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.

1-2. Self-explanatory.
3-4. List anticipated starting and ending dates of assignment.
5.

Section II:

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.

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.

8-11. Self-explanatory.
12.

Section III:

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

1.

Self-explanatory.

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

2.

See FIC/ISB Technical Advisories No. 4 & 4A on patient contact at: http://www.nih.gov/fic/visiting/taindex.html.

15.

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.

List health insurance coverage only if not a U.S. citizen.

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.

19.

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

Note for renewals: See FIC/ISB Technical Advisory No. 11 for
eligibility criteria and instructions on submission of renewal requests for individuals who will exceed three years in J-1 status
(http://www.nih.gov/fic/visiting/taindex.html).

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:

whether you meet the criteria to provide volunteer services to NIH
or to use NIH facilities.

. 42 U. S. C. 282(b)(10) and 42 U.S.C. 284(b)(1)(K). These sec-

. institutions providing financial support;
. U. S. Office of Personnel Management for program evaluation

Routine Uses: Information furnished may routinely be disclosed to:

tions 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.

purposes;

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

. the General Accounting Office for fund disbursement determinations;

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 Department of Justice in the event of litigation;
. a congressional office responding to an inquiry from the person

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

. Federal agencies that are considering you for employment and

to whom the record pertains;
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 it displays a currently valid OMB
NIH 590 (Rev. 1/99)

Instructions Page.

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.