AD-2022 Student Volunteer Service Agreement

Form Approved –OMB No. 0560-0232

This form is available electronically.

AD-2022

U.S. DEPARTMENT OF AGRICULTURE
Farm and Foreign Agricultural Services

(04-13-11)

STUDENT VOLUNTEER PROGRAM SERVICE AGREEMENT
NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for requesting the information identified on this form is 5 USC 3111.
The information will be used to set conditions and obtain agreement concerning the acceptance of student volunteers in a non-pay status for educationally-related work assignments. The
information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the
information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for OPM/GOVT-1 - General Personnel Records. Providing the
requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility for the student volunteer to participate in this program.
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 0560-0232. 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE APPROPRIATE
AGENCY.

Student Volunteer is an individual who is enrolled not less than half-time in high school, trade school, technical or vocational institute,
junior college, college, university or other accredited educational institution who, with the permission of the institution at which
enrolled, voluntarily performs services as part of an agency program established for providing educational experience.
2. Telephone Number (Including Area Code)

1. Name of Student
3. Home Address (Including Zip Code)

4. Name of Educational Institution

5A. Authorized Signature

5B. Title

6. Student’
s Academic Status

8. Enter a check for applicable Agency:

5C. Date

7. Student’
s Major

FAS

FSA

RMA

This Agreement is for the purpose of setting conditions for the acceptance of students in a nonpay status for educationally-related work
assignments in compliance with the provision of 5 USC 3111.
The following conditions apply to this Agreement:
 Participant must be a student who is enrolled not less than half-time at the institution.
 Volunteer service is with the permission of the institution in which the student is enrolled.
 Service under this Agreement will not be compensated by the Agency.
 Volunteer service should be in accordance with appropriate Federal, State, and local regulations, regarding employment of minors.
 Students will not be used to displace any employee.
 Students are not considered to be Federal employees for any purpose other than the following:
a.
b.

Compensation for injuries sustained during the performance of work assignments, in accordance with the provisions of
5 USC Chapter 81.
Federal Tort Claims provisions of 28 USC 2671 through 2680.

 The Agency agrees to provide attendance and performance records to the institution as reasonably required in order for the
experience to be properly credited.
 The Institution agrees to refer the students without regard to race, creed, color, age, sex, physical handicap, or other non-merit
factors.
 The Agency agrees to endeavor to make the assignment beneficial to the academic aims of the student and the institution.

AD-2022 (04-13-11)

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9. I UNDERSTAND AND AGREE TO THE CONDITIONS OF MY SERVICE DESCRIBED ABOVE:
A.

B. Date (MM-DD-YYYY)

Student Signature

C. If under 18 years of age, Parent/Guar dian Signatur e

D. D ate (MM-DD-YYYY)

10. TO BE COMPLETED BY RESPONSIBLE AGENCY OFFICIAL:
A. Location (Address)

B. Brief description of duties

C. Effective Date (MM-DD-YYYY)

D. Fiscal Year

11A. Selec ting Official Signatur e

11B. D ate (MM-DD-YYYY)

12. TERMINATION OF AGREEMENT
A. Agreement Terminated On
(Month, Day, Year )

B. S ignatur e of R es ponsible Official

C. S ignatur e of Volunteer/Student

C

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’
s
income is derived from any public assistance program. (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 to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue,
S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 8456136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.