Form Nih 590 – Fill Out and Use This PDF

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

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. 8/11) Page 1 of 2 pages.

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

1. IC/Lab and Location (Building and room)

3.Local Address of Special Volunteer or Guest Researcher

2.Phone No.

4. Local Phone No.

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.

1-2. Self-explanatory.

3-4. List anticipated starting and ending dates of assignment.

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).

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 re- questing 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.

20.List NIH Supervisor or Host by name and organization.

21.List phone number of NIH Supervisor or Host.

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.

SECTION II:

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.

(http://dis.ors.od.nih.gov/forms/01_forms.html#checklist)

2.See DIS/ORS Technical Advisories on patient contact at: http://dis.ors.od.nih.gov/advisories/techadvisories.html.

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.

Pursuant to the Privacy Act of 1974, NIH provides the following ex- planation. 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 fa- cilities. 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.

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. 8/11) 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.