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 Annual Payback Activities Certification (APAC)

4.

Description of a) health-related research/teaching activities; b) field of research/training duties; and c) source of salary support. Include numbers of hours per week if not full time.

a.

     

PLEASE TYPE. See instructions and Privacy Act information in transmittal letter. Please complete applicable sections. This form can also be downloaded from http://grants.nih.gov/grants/forms.htm#training. Retain a copy for your files.

b.

     

c.

     

Section I – Payback Status (Check applicable blocks[s])

Section III – Employment Information When Engaged in Payback

1.

Have not engaged in payback service during reporting period. (Complete Section IV.)

NAME AND ADDRESS OF EMPLOYING ORGANIZATION      

NAME OF SUPERVISOR      

2.

Have elected to engage in financial payback. (Complete Section IV.)

3.

Request an extension of the 2-year period to initiate payback service or a break in service. Also check this box if you need an extension to participate in any of the NIH Loan Repayment Programs. (Specify need and length of extension under Section II, Item 4; complete Section IV.)

TITLE      

4.

Have been engaged in continuous payback service during reporting period. (Complete Sections II, III, and IV.)

SIGNATURE OF SUPERVISOR OF RECORD

DATE

     

Section II – Payback Service Description

If supervisor is retired or deceased or if you, the recipient, are self-employed, provide notarized statement that reported employment information is accurate.

1.

Number of months engaged in payback during this reporting period:

     

Section IV – Certification of Kirschstein-NRSA Recipient

Dates: (mm/dd/yyyy – mm/dd/yyyy)

     

I certify that all of the above statements are true, complete, and correct to the best of my knowledge. (A willfully false certification is a criminal offense. U.S. Code, Title 18, Section 1001).

2.

Position Title :

     

SIGNATURE

DATE

     

3.

Payback Service

SOCIAL SECURITY NO. XXX-XX-    

DAYTIME TELEPHONE NO.      

E-MAIL      

a.

Full-time position with biomedical or behavioral health-related research, health-related teaching, and/or health-related activities as primary activity.

Section V – Acceptance by PHS Official (leave blank)

b.

Other position(s) where biomedical or behavioral health-related research, health-related teaching, and/or health-related activities averages at least 20 hours per week of a full work year.

NAME AND TITLE OF PHS OFFICIAL      

Extension date payback service to begin or resume

Number of months of acceptable service this reporting period

     

     

SIGNATURE

DATE

     

Section VI – Recipient Name and Address Update

NAME AND ADDRESS (Please correct if name and/or address has changed.)      

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
National Institutes of Health
Bethesda, MD 20892

To: Former Ruth L. Kirschstein National Research Service Awardees

Payback Requirements

Under Section 487 of the Public Health Service (PHS) Act as amended (42 USC 288), all individuals other than prebaccalaureate students who received a Ruth L. Kirschstein National Research Service Award (NRSA) prior to June 10, 1993, must engage in biomedical or behavioral health-related research and/or health-related teaching for a period equal to the period of Kirschstein-NRSA support in excess of 12 months.*

For Kirschstein-NRSA recipients who began appointments to training grants or activated fellowship awards on or after June 10, 1993, only the first twelve months of postdoctoral support will incur a service payback obligation. Such individuals may satisfy that obligation by engaging in an equal period of health-related research, health-related teaching, or health-related activities or by receiving an equal period of Kirschstein-NRSA supported postdoctoral research training. Kirschstein-NRSA postdoctoral support beyond the initial 12 months may also be used to satisfy a postdoctoral service obligation incurred for awards which began before June 10, 1993.

By regulation (42 CFR Part 66), this service must be initiated within two years after termination of Kirschstein-NRSA support. If payback service is not started within the 2-year period, financial payback will become due unless an extension of the period of undertaking payback or a waiver request has been approved by the PHS.

Annual Payback Activities Certification, Form PHS 6031-1

The enclosed Annual Payback Activities Certification (APAC) form is the basic communication between former Kirschstein-NRSA recipients and the PHS. Regardless of the nature of your present activities, complete and return the form. Do not hesitate to provide supplemental information or request clarification of your obligation from the PHS agency that supported your training.

Special Instructions for APAC

Follow the instructions on the APAC form together with these instructions. This form may be filled out online and printed for submission to PHS. It also may be downloaded, printed, and completed. If you need more than one form to cover the reporting period, duplicate the form and clearly label them at the top “#1 of 2 certifications,” etc. This form is available at: http://grants.nih.gov/grants/ forms.htm #training.

Section I

Item 1. Not Engaged: If this APAC is received in the first year after the termination of your Kirschstein-NRSA support and you are not electing financial payback or requesting an extension of the 2-year period in which to initiate payback, sign and return the form; no further information is required. If the APAC covers the second year after termination of your Kirschstein-NRSA support, financial payback will be due 24 months after the termination date unless a request for an extension of the payback initiation period or a payback waiver is submitted and approved.

Item 2. Financial Payback: Those electing financial payback will be contacted by the PHS with appropriate instructions.

Item 3. Extension: Reasons for an extension or break in service include such things as physicians completing residency training, graduate students completing degree requirements, temporary disability or substantial hardship. This item should also be used to report participation in any of the NIH Loan Repayment Programs (LRP). Participation in LRP will result in a deferral of the NRSA obligation because concurrent payback under both LRP and NRSA is not permissible. If requesting an extension because of LRP participation, include the start and end date of your LRP in Section II.4.

Item 4. Engaged in Payback Service: This item includes regular payback service (biomedical or behavioral health-related research, teaching, and/or activities). For additional information on acceptable payback service, see the Payback section of the most recent version of the NIH Grants Policy Statement found at http://grants.nih.gov/grants/policy/policy.htm.

Section II

Item 1. Number of Months: Indicate the number of months and dates (mm/dd/yyyy) engaged in payback service during this reporting period. Do not include any service already reported on previous APACs submitted.

Item 4. Description of Duties: The description of regular service should include sufficient information to serve as the basis for determination of acceptability. It should include: (a) the specific activities (research, teaching, health-related activities, etc.); (b) field of research/training duties; and (c) the source(s) of salary supporting the activities. Include number of hours per week if not full time and the dates covered by each activity, if different from those in Section II, Item 1.

Section III

This section must be completed and signed by the supervisor(s) of record.

Section IV

For those engaged in payback service, the APAC should be signed on or after the end date reported in Section II, Item 1. The PHS requests the last four digits of the Social Security Number in order to maintain accurate payback records for former Kirschstein-NRSA trainees and fellows and is authorized to collect this information under Section 487 of the Public Health Service Act. Providing your Social Security Number is voluntary and you will not be deprived of any Federal rights, benefits or privileges for refusing to disclose it.

Preprinted Information

Address Verification: Until your payback obligation is completed, report immediately any change in name or address to the Kirschstein-NRSA Payback Service Center.

Reporting Period: Report only those activities occurring within the time period shown on the form. The APAC form is forwarded annually by the PHS until the payback obligation is complete.

Record of Payback Obligation: The legislative allowance, when applicable, reflects the individual’s initial 12 months of support under the Kirschstein-NRSA funding authority which on appointments or fellowship awards started prior to June 10, 1993, was not subject to payback.* Service credited is obtained from previous APAC reports.

Mailing

Return the completed APAC(s) with the necessary signatures, and one copy of any attachment(s), no later than 30 days after the reporting period end date to the address below. When the payback service or extension request is approved by PHS, a copy of the APAC will be returned to you.

For any questions, please contact:

NRSA Payback Service Center

Office of Extramural Programs

OER/OD/National Institutes of Health

6011 Executive Boulevard, Suite 206, MSC 7650

Bethesda, MD 20892-7650

Phone: (301) 594-1835 or (866) 298-9371

NIH estimates that it will take 20 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.

* Individuals in delinquent payback status prior to August 13, 1981, have a payback obligation for the total amount of time of Kirschstein-NRSA support.

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 facilitate postaward management and evaluation of PHS programs. The social security number is requested to provide a reliable identifier that will assist in establishing an accurate and complete record for each individual. It is particularly useful in maintaining effective communication with those individuals who have incurred payback obligations through their participation in the Ruth L. Kirschstein National Research Service Award program. Failure to provide the social security number may seriously diminish PHS’s capability to credit the account of the proper trainee who is fulfilling the payback requirement by either acceptable service and/or monetary repayment.

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.

Some routine uses may be:

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).

PHS 6031-1 (Rev. 10/08)