Form Attachment 9 Attachment 9 Fellowship Activation Notice

Form Approved Through 06/30/2015

OMB No. 0925-0001
FELLOWSHIP NUMBER

Department of Health and Human Services
Public Health Service

Ruth L. Kirschstein National Research Service Award

Individual Fellowship Activation Notice

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

1. All fellows must complete this form for the first year of their
4. For Ruth L. Kirschstein National Research Service Award fellows
fellowship, indicating their start date under the fellowship and
in their first 12 months of postdoctoral support, a signed payback
other requested information. Fellows training at Federal and
agreement MUST accompany this form.
foreign institutions who are paid directly by the Public Health
Service must complete this form for EACH year of the fellowship. 5. No funds may be disbursed until the fellow enters on duty and the
proper forms are submitted to PHS.
For the latter, use the fellowship number and the entry date for the
latest year, and provide mailing addresses.
6. As a condition of this activation, all NRSA fellows agree to
complete and submit a Termination Notice (PHS 416-7)
2. Send the signed original of the completed form to the awarding
immediately upon completion of support.
agency using the address provided in the Notice of Award. This
should be submitted immediately after the fellow enters on duty.
NIH estimates that it will take 5 minutes to complete this form. This
Keep a copy; one will not be returned. This form may be filled out includes time for reviewing the instructions, gathering needed information,
online and then printed for submission to PHS. It also may be
and completing and reviewing the form. An agency may not conduct or
downloaded, printed, and completed with a typewriter.
sponsor, and a person is not required to respond to, a collection of
3. An appropriate statement regarding degrees (certified by degreegranting institution) MUST be attached if such contingency
appears on the award notice.

NAME OF FELLOW (Last, first, middle)

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 (0925-0001). DO
NOT RETURN THE COMPLETED FORM TO THIS ADDRESS.
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:
(FOR DIRECT PAY FELLOWS)
STIPEND
(monthly) $

Through:

SPECIAL INSTRUCTIONS
Total $

TRAVEL

$

OTHER

$

TOTAL PAYMENT

COMMON ACCOUNTING NO.

®

$

PREPARED BY:
DATE:

PHS 416-5 (Rev. 6/12)

SOCIAL SECURITY NO.

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