Amended 2271 Form

Form Approved Through 06/30/2012 OMB No. 0925-0001

Department of Health and Human Services Public Health Services Statement of Appointment (Please Type)

Follow attached instructions carefully. Submit this form at the time the individual is appointed, is reappointed, or the reported appointment is amended. Return this form to the PHS awarding component. For new postdoctoral trainees under NRSA, signed and dated payback agreement must accompany this form.

1. PHS GRANT NUMBER

2a. APPOINTEE’S NAME (Last, first, initial)

3. SEX

Type      

Activity      

ID Serial No.      

     

M F

2b. COMMONS ID

     

4. TYPE OF ACTION (Check only one type) NEW appointment (NOT previously supported by this grant) REAPPOINTMENT (Previously supported by this grant) AMENDMENT of items checked: 2 9 15 20

5. PRIOR NRSA SUPPORT (Individual or institutional) NO YES (If “Yes,” see instructions)

     

6. SOCIAL SECURITY NO. XXX-XX-     

7. BIRTHDATE (Month, day, year)      

8. CITIZENSHIP (See instructions) U.S. Citizen or Noncitizen National Non-U.S. Citizen With a Permanent U.S. Resident Visa (“Green Card”) With a Temporary U.S. Visa If not a U.S. citizen, of which country are you a citizen?      

9. PERMANENT MAILING ADDRESS      

E-mail

     

10. Are you Hispanic (or Latino)? YES NO Do Not Wish to Provide

11. What is your racial background? Check one or more American Indian or Alaska Native Native Hawaiian or other Pacific Islander Asian Black or African American White Do Not Wish to Provide

12. Do you have a disability?

YES NO Do Not Wish to Provide

If yes, which of the following categories describe your disability(ies):

Hearing

Mobility/Orthopedic Impairment

Visual

Other

13. Are you from a disadvantaged background?

YES NO Do Not Wish to Provide

14. FIELD OF RESEARCH TRAINING OR CAREER DEVELOPMENT (for this appointment)

15. PERIOD OF APPOINTMENT (Month, day, year)

Enter a 4 digit code from instructions:

  

  

  

  

From:      

To:      

16. EDUCATION – AFTER HIGH SCHOOL (Indicate all academic and professional education. For foreign degrees, give U.S. equivalent.)

(a) Name of Institution and Location (List most recent first)

(b) Degree(s) Received

(c) Major Field

(d) Minor Field

Degree

Mo./Yr.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

PHS 2271 (Rev. 06/09) Page 1 of 2