Form No. PHS 6349 Form No. PHS 6349 Annual HHS Report on Research Misconduct

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service

FORM APPROVED: OMB No. 0937-0198; Expires: 03/31/09
See Statement of Burden on Reverse

ANNUAL REPORT ON
POSSIBLE RESEARCH MISCONDUCT

Period Covered by this Report

January 1, 2008 to December 31, 2008
INSTITUTIONAL OFFICIAL'S NAME

Please make any mailing changes in the space to the right:

INSTITUTIONAL OFFICIAL'S TITLE

NAME OF INSTITUTION

MAILING ADDRESS OF INSTITUTIONAL OFFICIAL
Place mailing label here.

Section I. Administrative Policy
Each institution which receives or applies for a PHS research, research-training or research-related grant or cooperative agreement must have
established an administrative policy for responding to allegations of research misconduct that complies with the PHS regulation (42 CFR Part 93) and
certify that it will comply with that policy. This regulation does not cover regulated research under the jurisdiction of the Food and Drug Administration
(FDA).

.

Has your institution established the administrative policy for responding to allegations of research misconduct required by the PHS regulation?
Yes

No

Section II. Types of Misconduct Activity Related to PHS Applications and Awards
A.

PLEASE CHECK THE BOX (to the left) if your institution has NOT received any allegations or conducted any inquiries or investigations
of allegations during the reporting period that (1) fall under the PHS definition of research misconduct and (2) involve receipt of or
requests for PHS funding, then complete Section III. Otherwise, please complete Section II.

B.

Please provide the requested information for each incident of alleged misconduct that involved a request for or receipt of PHS funds that fell within
the PHS definition of research misconduct. Please note that, in accordance with section 93.310(b), all investigations are to be reported to the
Office of Research Integrity (ORI) before or immediately upon commencement of the investigation.

PLEASE NOTE: For each incident of alleged research misconduct resulting in an allegation, inquiry, and/or investigation at your institution:
(1) provide the ORI case number, if assigned; (2) check the type of activity (allegation, inquiry, and/or investigation -- may include more
than one activity type for each reported incident); and (3) check the type of misconduct involved with each activity (may include more than
one type of misconduct). Attach a separate sheet if additional space or clarification is required.
Do NOT include any alleged fiscal misconduct, human or animal subject abuses, conflicts of interest, or violations of FDA regulated
research.
1. Activity continued into 2008:

ORI Case Number,
if assigned

Type of Activity

Incident
Number
1.

Type of Misconduct
Fabrication

Falsification

Plagiarism

Inquiry . . . . . . . . . . .
Investigation . . . . . .

2.

Inquiry . . . . . . . . . . .
Investigation . . . . . .

3.

Inquiry . . . . . . . . . . .
Investigation . . . . . .
Continued on back

PHS-6349 (Front)
Rev. 11/08

P S C G ra p h ics : (3 0 1 ) 4 4 3 -1 0 9 0

E

Section II. (Continued)
B.

(Continued)
2. Activity begun in 2008:

ORI Case Number,
if assigned

Type of Activity

Incident
Number

Type of Misconduct
Fabrication

1.

Falsification

Plagiarism

Allegation . . . . . . . .
Inquiry . . . . . . . . . . .
Investigation . . . . . .
Allegation . . . . . . . .

2.

Inquiry . . . . . . . . . . .
Investigation . . . . . .
3.

Allegation . . . . . . . .
Inquiry . . . . . . . . . . .
Investigation . . . . . .

Section III. Certification
Official Certifying for Institution:
NAME OF OFFICIAL (Please type)

TITLE

SIGNATURE

DATE

TELEPHONE NUMBER

(

FAX NUMBER

)

(

)

E-MAIL ADDRESS OF OFFICIAL:

STATEMENT OF BURDEN
Public reporting burden for this collection of information is estimated to
average 10 minutes to complete the form, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining
the data needed and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing
this burden to: OS Reports Clearance Officer, Hubert H. Humphrey
Building, Room 503-H, 200 Independence Avenue, S.W., Washington,
D.C. 20201 (Attn: PRA) and to: Office of Management and Budget,
Paperwork Reduction Project (0937-0198) Washington, D.C. 20502.
Please do not return this form to either of these addresses.
PHS-6349 (Back)
Rev. 11/08

RETURN THIS FORM TO:
Assurance Program
Office of Research Integrity
1101 Wootton Parkway, Suite 750
Rockville, MD 20852
Phone: (240) 453-8400
FAX: (301) 594-0042
E-Mail: [email protected]