Form 1 form

Form Approved Through 10/31/2011 OMB No. 0925-0002

Department of Health and Human Services Public Health Service Ruth L. Kirschstein National Research Service Award Individual Fellowship Activation Notice

FELLOWSHIP NUMBER      

DATE FELLOW ENTERED ON DUTY (Month, day, year)      

1. All fellows must complete this form for the first year of their fellowship, indicating their start date under the fellowship and other requested information. Fellows training at Federal and foreign institutions who are paid directly by the Public Health Service must complete this form for EACH year of the fellowship. For the latter, use the fellowship number and the entry date for the latest year, and provide mailing addresses. 2. Send the signed original of the completed form to the awarding agency using the address provided in the Notice of Award. This should be submitted immediately after the fellow enters on duty. Keep a copy; one will not be returned. This form may be filled out online and then printed for submission to PHS. It also may be downloaded, printed, and completed with a typewriter. 3. An appropriate statement regarding degrees (certified by degree-granting institution) MUST be attached if such contingency appears on the award notice.

4. For Ruth L. Kirschstein National Research Service Award fellows in their first 12 months of postdoctoral support, a signed payback agreement MUST accompany this form. 5. No funds may be disbursed until the fellow enters on duty and the proper forms are submitted to PHS. 6. As a condition of this activation, all NRSA fellows agree to complete and submit a Termination Notice (PHS 416-7) immediately upon completion of support. NIH estimates that it will take 5 minutes to complete this form. This includes time for reviewing the instructions, gathering needed information, and completing and reviewing the form. 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 control number. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send comments to: NIH, Project Clearance Office, 6705 Rockledge Drive MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0002). DO NOT RETURN THE COMPLETED FORM TO THIS ADDRESS.

NAME OF FELLOW (Last, first, middle)      

RETURN TO: The awarding agency using the address provided on the Notice of Award. Contact the assigned Grants Management Specialist for questions.

HIGHEST DEGREE(S)      

NAME OF SPONSORING INSTITUTION      

Fellows Sponsored by (training at) Federal or Foreign Institutions*

FULL ADDRESS WHERE CHECKS SHOULD BE MAILED      

RESIDENTIAL ADDRESS (Street, City, State, Zip Code)      

* Foreign-sponsored fellows are encouraged to have monthly stipend checks deposited in a financial institution located in the United States because of past delays encountered in foreign mail deliveries. Fellows are responsible for making the financial arrangements of their choosing; include account number, name, and mailing address of the financial institution above. Annual income statements will be mailed to the residential address.

REQUIRED SIGNATURES

FELLOW

E-MAIL      

PHONE NO.      

DATE      

SPONSOR

E-MAIL      

PHONE NO.      

DATE      

INSTITUTIONAL BUSINESS OFFICIAL

E-MAIL      

PHONE NO.      

DATE      

DO NOT WRITE IN THIS BLOCK (For PHS use only)

AWARD PERIOD From: Through:

COMMON ACCOUNTING NO.

SOCIAL SECURITY NO. XXX-XX-

(FOR DIRECT PAY FELLOWS)

SPECIAL INSTRUCTIONS

STIPEND (monthly) $

Total $

TRAVEL $

OTHER $

TOTAL PAYMENT ®

$

PREPARED BY:

DATE:

PHS 416-5 (Rev. 10/08)

Privacy Act Statement

The Public Health Service requests this information pursuant to statutory authorities contained in Section 405(a) and 487 of the Public Health Service Act, as amended (42 USC 284(b)(1)C and 288), and other statutory authorities (42 USC 242(a), 280(b)(4), and 29 USC 670). The information collected will assist in activating the award and facilitate postaward management and evaluation of PHS programs. Although providing the information is voluntary, an individual may not receive support from the grant until the form is submitted.

The PHS maintains application and grant records as part of a system of records as defined by the Privacy Act: 09-25-0036, “Extramural Awards and Chartered Advisory Committees.” The Privacy Act of 1974 (5 USC 552a) allows disclosures for “routine uses” and permissible disclosures.

Routine uses include:

1. To the cognizant audit agency for auditing.

2. To a Congressional office from a record of an individual in response to an inquiry from the Congressional office made at the request of that individual.

3. To qualified experts, not within the definition of DHHS employees as prescribed in DHHS regulations (45 CFR 5b.2) for opinions as part of the application review process.

4. To a Federal agency, in response to its request, in connection with the letting of a contract or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the record is relevant and necessary to the requesting agency’s decision on the matter.

5. To organizations in the private sector with whom PHS has contracted for the purpose of collating, analyzing, aggregating, or otherwise refining records in a system. Relevant records will be disclosed to such a contractor, who will be required to maintain Privacy Act safeguards with respect to such records.

6. To the sponsoring organization in connection with the review of an application or performance or administration under the terms and conditions of the award, or in connection with problems that might arise in performance or administration if an award is made.

7. To the Department of Justice, to a court or other tribunal, or to another party before such tribunal, when one of the following is a party to litigation or has any interest in such litigation, and the DHHS determines that the use of such records by the Department of Justice, the tribunal, or the other party is relevant and necessary to the litigation and would help in the effective representation of the governmental party.

a. the DHHS, or any component thereof;

b. any DHHS employee in his or her official capacity;

c. any DHHS employee in his or her individual capacity where the Department of Justice (or the DHHS, where it is authorized to do so) has agreed to represent the employee; or

d. the United States or any agency thereof, where the DHHS determines that the litigation is likely to affect the DHHS or any of its components.

8. A record may also be disclosed for a research purpose, when the DHHS:

a. has determined that the use or disclosure does not violate legal or policy limitations under which the record was provided, collected, or obtained;

b. has determined that the research purpose (1) cannot be reasonably accomplished unless the record is provided in individually identifiable form, and (2) warrants the risk to privacy of the individual that additional exposure of the record might bring;

c. has secured a written statement attesting to the recipient’s understanding of, and willingness to abide by, these provisions; and

d. has required the recipient to:

(1) Establish reasonable administrative, technical, and physical safeguards to prevent unauthorized use or disclosure of the record;

(2) Remove or destroy the information that identifies the individual at the earliest time at which removal or destruction can be accomplished consistent with the purpose of the research project, unless the recipient has presented adequate justification of a research or health nature for retaining such information; and

(3) Make no further use or disclosure of the record, except (a) in emergency circumstances affecting the health or safety of any individual, (b) for use in another research project, under these same conditions, and with written authorization of the DHHS, (c) for disclosure to a properly identified person for the purpose of an audit related to the research project, if information that would enable research subjects to be identified is removed or destroyed at the earliest opportunity consistent with the purpose of the audit, or (d) when required by law.

The Privacy Act also authorizes discretionary disclosures where determined appropriate by the PHS, including to law enforcement agencies, to the Congress acting within its legislative authority, to the Bureau of the Census, to the National Archives, to the General Accounting Office, pursuant to a court order, or as required to be disclosed by the Freedom of Information Act of 1974 (5 USC 552) and the associated DHHS regulations (45 CFR Part 5).