Form 1 2271

Research and Research Training Grant Applications and Related Forms

phs2271

2271

OMB: 0925-0001

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Instructions for PHS 2271 Form Approved Through 9/30/2010

Revised 9/2007 OMB No. 0925-0001

U.S. Department of Health and Human Services
Public Health Service

Information and Instructions for Completing
Statement of Appointment (Form PHS 2271)

The Public Health Service (PHS) estimates that it will take 15 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 the amount of time it takes to complete this form or any other aspects 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 20592-7974, ATTN: PRA (0925-0001). Do not return the completed form to this address.

I. INTRODUCTION

This form is to be used to appoint individuals as trainees to institutional Ruth L. Kirschstein-National Service Research Award (Kirschstein-NRSA) programs (e.g., T32, T34, T35) and non-NRSA institutional research training programs (e.g., T15). It can also be used to document the appointment of scholars to institutional career development awards (e.g., K12) and individual participants to research education awards (e.g., R25).

Please read carefully the following instructions, including the Privacy Act Statement at the end of this document. All items on the form must be completed unless otherwise indicated in these instructions.

II. GENERAL INSTRUCTIONS

A. Definitions:

Types of Awards

Kirschstein-NRSA. Awards that provide undergraduate, predoctoral, and postdoctoral research training support under the authority of Section 487 of the PHS Act (42 USC 288). All Kirschstein-NRSA trainees must meet specific citizenship requirements – for details, see Item 8.

Non-NRSA Research Training. Awards that provide predoctoral and postdoctoral research training support through non-NRSA funding authorities. These training programs generally do not have the same provisions and requirements as Kirschstein-NRSA awards (e.g., specific citizenship requirements).

Career Development. Awards that provide doctoral-level investigators an opportunity to enhance their research careers. Individuals appointed to institutional career development awards must meet specific citizenship requirements—for details, see Item 8.

Research Education. Awards that provide support for programs intended to attract investigators to a specific field of study. Individuals appointed to research education award programs may or may not be subject to specific citizenship requirements—for details, see Item 8.

Types of Appointments

Trainee. A person appointed to and supported by an institutional Kirschstein-NRSA or non-NRSA research training award.

Scholar. A person appointed to and supported by an institutional career development award.

Participant. A person appointed to and supported by a research education award.

B. Application

A “Statement of Appointment” form covers the support of an individual for a particular budget period and is required for each new appointment, reappointment, or amended appointment of an individual receiving stipend, tuition costs, or travel expenses as a trainee under a PHS institutional training grant, or salary as a scholar or participant under a career development or research education program award in which the institution selects and appoints the individual. The form (which is signed by both the individual and the Program Director) must be completed and submitted to PHS at the time the individual starts the appointment or reappointment, or, in the case of an amendment, as soon as the change occurs. If there are multiple Program Directors on the award, the contact PD should sign.

For new postdoctoral trainees appointed to Kirschstein-NRSA institutional grants, a signed and dated payback agreement must be submitted with this appointment form before a stipend or other allowance may be paid.

C. Submission

The original should be sent to the awarding component. A copy should also be given to the trainee, scholar, or participant, the Program Director, and Business Official.

III. ITEM-BY-ITEM INSTRUCTIONS

Item 1. PHS Grant Number. Insert the entire PHS Grant Number as shown on the particular Notice of Grant Award from which funds are provided, e.g., 5 T32 GM12453-03 would be listed as
Type: 5; Activity Code: T32; ID Serial Number: GM12453-03.

Item 2. Trainee/Scholar/Participant Name. Include maiden name or other names in parentheses where applicable.

Item 3. Sex. Self-explanatory.

Item 4. Type of Action.

New Appointment: When an individual has not been previously supported by this training grant.

Reappointment: When an individual was supported by this grant during a previous budget period, the appointment covered by this form is designated a reappointment. Skip the shaded items if the information provided will be the same as that reported during the prior budget period. Always complete the non-shaded items.

Amendment: “Amendment” pertains only to a change of item 2 (Name); 9 (Permanent Mailing Address); 15 (Appointment Period); or 20 (Support from this Grant) during a period of appointment for which a “Statement of Appointment” form has already been submitted. Amendments must be submitted as soon as the change occurs. Complete only items 1, 2, 4, 6, 22, 23, and the item(s) to be amended.

Item 5. Prior NRSA Support. Individuals being appointed to a Kirschstein-NRSA institutional grant for the first time or being reappointed after a break in support must indicate if they have received prior Kirschstein-NRSA support from either an individual award or institutional grant. If yes, specify on the form the dates of support, the level (pre- or post-), the mechanism (individual award or institutional grant), and the grant number, if known. (See the Program Guidelines for limitations on total period of support.)

Item 6. Social Security Number. Trainees/scholars/participants are asked to voluntarily provide the last four digits of their Social Security Numbers. This information provides the agency with vital information necessary for accurate identification and review of appointments and for management of PHS grant programs. See the Privacy Act Statement at the end of these instructions for further information concerning this request.

Item 7. Birthdate. Self-explanatory.

Item 8. Citizenship. Check the box corresponding to the trainee’s, scholar’s, or participant’s citizenship and visa status. If not a U.S. citizen, list the country of citizenship.

A noncitizen national is an individual who, although not a citizen of the United States, owes permanent allegiance to the United States. Individuals in this category are generally born in lands which are not States, but which are under U.S. sovereignty, jurisdiction, or administration (e.g., American Samoa).

Kirschstein-NRSA trainees and institutional career development scholars must be U.S. citizens, non-citizen nationals, or permanent residents of the United States. Individuals on temporary or student visas are not eligible. Trainees or scholars in these programs who are permanent residents of the U.S. must submit a notary’s signed statement with this appointment form certifying that they have (1) a Permanent Resident Card (USCIS Form I-551), or (2) other legal verification of such status.

Trainees in non-NRSA research training programs and participants in research education award programs should consult the applicable Funding Opportunity Announcement (FOA) for citizenship requirements.

Item 9. Permanent Mailing Address. Give an address where the appointed individual can be reached by mail after completion of the program. (Do not give present address unless it is considered permanent as defined above.)

Items 10-13. Race/Ethnicity/Disability/Disadvantaged Background. Responses to these items will help provide statistical information on the participation of individuals from diverse groups in Public Health Service (PHS) programs and identify inequities in terms of recruitment and retention based on race, ethnicity, disability and/or disadvantaged background.

Trainees, scholars, and participants are strongly encouraged to provide this information, however declining to do so will in no way affect their appointments.

This information will be retained by the PHS in accordance with and protected by the Privacy Act of 1974. Racial/ethnic/disability/background data are confidential and all analyses utilizing the data will report aggregate statistical findings only and will not identify individuals. (See the Privacy Act Statement at the end of these instructions for more information.)

10. Are you Hispanic (or Latino)?

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino”.

11. What is your racial background?
Check one or more.

American Indian or Alaska Native. A person having origins in any of the original peoples of North, Central, or South America and maintains tribal affiliation or community.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

12. Do you have a disability?

Disability: A physical or mental impairment that substantially limits one or more major life activities.

13. Are you from a disadvantaged background?

Disadvantaged Background: An individual is considered to be from a disadvantaged background if he or she:

1. Comes from a family with an annual income below established low-income thresholds, published by the U.S. Bureau of the Census; adjusted annually for changes in the Consumer Price Index; and adjusted by the Secretary for use in all health professions programs. The Secretary periodically publishes these income levels at http://aspe.hhs.gov/poverty/ index.shtml. Individuals falling in this category must have qualified for Federal disadvantaged assistance or have received Health Professional Student Loans (HPSL), Loans for Disadvantaged Student Program, or scholarships from the U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need.

2. Comes from a social, cultural, or educational environment, such as that found in certain rural or inner-city environments, that has demonstrably and recently directly inhibited the acquisition of the knowledge, skills, and abilities necessary to develop and participate in a research career. This category is most applicable to high school and perhaps undergraduate students, but more difficult to justify for individuals beyond that level of achievement.

Item 14. Field of Training (FOT). Provide a single numeric FOT code from the list below that best fits the research training that will be provided during the appointment. Use the subcode (nonbold lowercase) unless the broader category (bold uppercase) fits best.

1000 I. Predominantly Non-Clinical or Lab-Based Research Training

1100 BIOCHEMISTRY

1110 Biological Chemistry

1120 Bioenergetics

1130 Enzymology

1140 Metabolism

1200 BIOENGINEERING

1210 Bioelectric/Biomagnetic

1220 Biomaterials

1230 Biomechanical Engineering

1240 Imaging

1250 Instrumentation and Devices

1260 Mathematical Modeling

1270 Medical Implant Science

1280 Nanotechnology

1290 Rehabilitation Engineering

1310 Tissue Engineering

1400 BIOPHYSICS

1410 Kinetics

1420 Spectroscopy

1430 Structural Biology

1440 Theoretical Biophysics

1500 BIOTECHNOLOGY

1510 Applied Molecular Biology

1520 Bioprocessing and Fermentation

1530 Metabolic Engineering

1600 CELL AND DEVELOPMENTAL BIOLOGY

1610 Cell Biology

1620 Developmental Biology

1700 CHEMISTRY

1710 Analytical Chemistry

1720 Bioinorganic Chemistry

1730 Bioorganic Chemistry

1740 Biophysical Chemistry

1750 Medicinal Chemistry

1760 Physical Chemistry

1770 Synthetic Chemistry

1900 ENVIRONMENTAL SCIENCES

2000 GENETICS

2010 Behavioral Genetics

2020 Developmental Genetics

2030 Genetic Epidemiology

2040 Genetics of Aging

2050 Genomics

2060 Human Genetics

2070 Molecular Genetics

2080 Population Genetics

2200 IMMUNOLOGY

2210 Asthma and Allergic Mechanisms

2220 Autoimmunity

2230 Immunodeficiency

2240 Immunogenetics

2250 Immunopathology

2260 Immunoregulation

2270 Inflammation

2280 Structural Immunology

2290 Transplantation Biology

2310 Vaccine Development

2400 MICROBIOLOGY AND INFECTIOUS DISEASES

2410 Bacteriology

2420 Etiology

2430 HIV/AIDS

2440 Mycology

2450 Parasitology

2460 Pathogenesis of Infectious Diseases

2470 Virology

2600 MOLECULAR BIOLOGY

2800 NEUROSCIENCE

2810 Behavioral Neuroscience

2820 Cellular neuroscience

2830 Cognitive neuroscience

2840 Communication Neuroscience

2850 Computational Neuroscience

2860 Developmental Neuroscience

2870 Molecular Neuroscience

2880 Neurochemistry

2890 Neurodegeneration

2910 Neuropharmacology

2920 Systems/Integrative Neuroscience

3100 NUTRITIONAL SCIENCES

3200 PHARMACOLOGY

3210 Molecular Pharmacology

3220 Pharmacodynamics

3230 Pharmacogenetics

3240 Toxicology

3300 PHYSIOLOGY

3310 Aging

3320 Anesthesiology (basic science)

3330 Endocrinology (basic science)

3340 Exercise Physiology (basic science)

3350 Integrative Biology

3360 Molecular Medicine

3370 Physiological Optics

3380 Reproductive Physiology

3500 PLANT BIOLOGY

3600 PSYCHOLOGY, NON-CLINICAL

3610 Behavioral Communication Sciences

3620 Behavioral Medicine (non-clinical)

3630 Cognitive Psychology

3640 Developmental and Child Psychology

3650 Experimental & General Psychology

3660 Mind-Body Studies

3680 Neuropsychology

3690 Personality and Emotion

3710 Physiological Psychology & Psychobiology

3720 Psychology of Aging

3730 Psychometrics

3740 Psychophysics

3750 Social Psychology

3900 PUBLIC HEALTH

3910 Disease Prevention and Control

3920 Epidemiology

3930 Health Economics

3940 Health Education

3950 Health Policy Research

3960 Health Services Research

3970 Occupational and Environmental Health

4100 RADIATION, NON-CLINICAL

4110 Nuclear Chemistry

4120 Radiation Physics

4130 Radiobiology

4200 SOCIAL SCIENCES

4210 Anthropology

4220 Bioethics

4230 Demography & Population Studies

4240 Economics

4250 Education

4260 Language and Linguistics

4270 Sociology

4400 STATISTICS AND/OR RESEARCH METHODS AND/OR INFORMATICS

4410 Biostatistics and/or Biometry

4420 Bioinformatics

4430 Computational Science

4440 Information Science

4450 Clinical Trials Methodology

4600 TRAUMA, NON CLINICAL

5000 OTHER, Predominantly Non-Clinical or Lab-Based Research Training

6000 II. Predominantly Clinical Research Training (can include any degree)

6100 ALLIED HEALTH

6110 Audiology

6120 Community Psychology

6130 Exercise Physiology (clinical)

6140 Medical Genetics

6150 Occupational Health

6160 Palliative Care

6170 Physical Therapy

6180 Pharmacy

6190 Social Work

6210 Speech-language Pathology

6211 Rehabilitation

6400 DENTISTRY

6500 CLINICAL DISCIPLINES

6510 Allergy

6520 Anesthesiology

6530 Behavioral Medicine (clinical)

6540 Cardiovascular Diseases

6550 Clinical Laboratory Medicine

6560 Clinical Nutrition

6570 Clinical Pharmacology

6580 Complementary and Alternative Medicine

6590 Clinical Psychology

6610 Connective Tissue Diseases

6620 Dermatology

6630 Diabetes

6640 Gastroenterology

6650 Endocrinology

6660 Immunology

6670 Gene Therapy (clinical)

6680 Geriatrics

6690 Hematology

6710 HIV/AIDS

6820 Infectious Diseases

6830 Liver Diseases

6840 Metabolic Diseases

6850 Nephrology

6860 Neurology

6870 Ophthalmology

6880 Nuclear Medicine

6890 OB-GYN

6910 Oncology

6920 Orthopedics

6930 Otorhinolarynology

6940 Preventive Medicine

6950 Radiation, Interventional

6960 Pulmonary Diseases

6970 Radiology, Diagnostic

6980 Rehabilitation Medicine

6990 Psychiatry

7110 Surgery

7120 Trauma

7130 Urology

7300 PEDIATRIC DISCIPLINES

7310 Pediatric Endocrinology

7320 Pediatric Hematology

7330 Pediatric Oncology

7340 Pediatric, Prematurity & Newborn

7500 NURSING

7700 VETERINARY MEDICINE

8000 OTHER, Predominantly Clinical Research Training

Item 15. Period of this Appointment. The period shown in most cases will be 12 months. Appointment periods may exceed 12 months in rare cases and only with prior approval from the PHS. The amount of the stipend/salary and tuition for each full period of appointment must be obligated from funds available at the time the appointment begins, unless other arrangements have been made with PHS.

Other instructions should be requested where institutional accounting practice precludes obligations of stipend/salary and tuition in the amount required for the full appointment period.

Item 16. Education. List undergraduate, master’s, and doctoral degrees and the month and year earned.

Item 17. Specialty Boards. If applicable, select a specialty from the attached list. If not applicable, indicate N/A.

Items 18-19. Degrees Sought. Provide the degree sought under the award. Indicate whether the appointee is in a dual degree program (e.g., M.D./Ph.D.).

Include the date that all degree requirements are expected to be completed.

Item 20. Support for Period of Appointment. Indicate the total amount the appointee expects to receive from the grant during the appointment period.

Item 21. Statement of Nondelinquency on U.S. Federal Debt. A “Statement of Nondelinquency on Federal Debt” is required for each particular appointment period and is to be completed by each individual (trainee) appointed to receive financial support under a PHS institutional training grant.

If the prospective trainee is delinquent on Federal debt, the PHS must review the explanation required to be provided on, or attached to, the form. In such case the PHS shall (a) take such information into account when determining whether the prospective trainee is responsible with respect to that appointment, and (b) consider not approving the appointment until payment is made or satisfactory arrangements are made with the agency to whom the debt is owed.

Therefore, it may be necessary for the PHS to contact the prospective trainee before the appointment can be approved to confirm the status of the debt and ascertain the payment arrangements for its liquidation. Individuals failing to liquidate indebtedness to the Federal Government in a businesslike manner place themselves at risk of not receiving PHS financial assistance.

The PHS awarding component shall notify the sponsoring institution in writing of its decision regarding the approval of a prospective appointee where this form discloses delinquency on Federal debt.

The trainee must check the appropriate box. If the “Yes” box is checked, please provide an explanation in the space provided. The question applies only to the person requesting financial assistance, and does not apply to the person who signs the form as the Program Director.

Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student loans, FHA loans, business loans, and other miscellaneous administrative debts. For purposes of this certification, the following definitions of “delinquency” apply:

• For direct loans and fellowships (whether awarded directly to the applicant by the Federal Government or by an institution using Federal funds), a debt more than 31 days past due on a scheduled financial payment. (This definition excludes service payback under a National Research Service Award.)

• For guaranteed and insured loans, recipients of a loan guaranteed by the Federal Government that the Federal Government has repurchased from a lender because the borrower breached the loan agreement and is in default.

• For grants, organizations in receipt of a “Notice of Grants Cost Disallowance” which have not repaid the disallowed amount or which have not resolved the disallowance. (This definition excludes disallowance in an “appeal” status.)

Item 22. Certification and Signature of Appointee. Self-explanatory.

Item 23. Certification, Signature, and Address of Program Director. Self-explanatory.

Privacy Act Statement

The PHS maintains application and grant records as part of a system of records as defined by the Privacy Act: 09-25-0112, Grants and Cooperative Agreements: Research, Research Training, Fellowship, and Construction Applications and Related Awards. The Privacy Act of 1974 (5 USC 522a) 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 the 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) 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 2271 (Rev. 9/2007) — Instructions

File Type	application/msword
File Title	PHS 2271 (Rev. 9/2007), Statement of Training Appointment
Subject	DHHS, Public Health Services
Author	DHHS, Public Health Services
Last Modified By	curriem
File Modified	2007-09-14
File Created	2007-09-14

17. NAME OF SPECIALTY BOARDS (if applicable)
18. DEGREE(S) SOUGHT YES NO	If yes, indicate type of degree
Are you in a dual degree program (e.g., M.D./Ph.D.)? YES NO
19. EXPECTED COMPLETION DATE OF DEGREE REQUIREMENTS (if applicable)
20. SUPPORT FOR PERIOD OF APPOINTMENT
TYPE		Total for this Grant (Omit cents)
Stipend / Salary / Other Compensation		$
Tuition/fees (estimated)		$
Travel (estimated)		$
TOTAL		$
21. STATEMENT OF NONDELINQUENCY ON U.S. FEDERAL DEBT. Is the appointee delinquent on the repayment of any U.S. Federal debt(s)?
NO YES (If “Yes,” please explain below.)

22. CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true and complete to the best of my knowledge and that I will comply with all applicable Public Health Service terms and conditions governing my appointment. I am aware that any false, fictitious or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.			(a) SIGNATURE OF APPOINTEE	(b) DATE

23. This individual is qualified for this program and is eligible to receive financial support for the period specified above. A copy of this appointment form will be given to the individual.			(a) SIGNATURE OF PROGRAM DIRECTOR	(b) DATE

(c) TYPED NAME OF PROGRAM DIRECTOR
(d) INSTITUTION’S NAME, ADDRESS, AND PHONE NO. (Street, city, state, zip code)