590 SV and GR Assignment form

OMB No. 0925-0177
Approved for use through February 28, 2021
New

Special Volunteer and
Guest Researcher Assignment

Renewal

Transfer
Termination, Date:
Special Volunteer (Provide services

Use prescribed by NIH Manual 2300 308-1

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) 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

10. Date of Birth

11. City & Country of Birth

permanent residence

(MM/DD/YY)

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

22. Approval Signature (For Special Volunteer--IC approving official.)

23. Date

(For Guest Researcher--IC Scientific Director) Signature Required.

NIH 590 (07/18)

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*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 (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

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

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

Date of entry into U.S.
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 I-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.

NIH 590 (07/18)

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

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.

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).

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. 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.

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.

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.

Privacy Act Statement

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 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 it displays a currently valid OMB

NIH 590 (07/18)

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