Form 1 PHS 416-7

Information and Instructions for Completing a
Termination Notice

(Completed form should be mailed to the PHS awarding agency Grants Management Office named in the Notice of Award)

This form summarizes the information to be supplied by Ruth L. Kirschstein National Research Service Award (NRSA) recipients on termination of their award and for a limited period thereafter. This form may also be used to document the termination of appointments to non-NRSA institutional research training programs (e.g., T15), research education awards (e.g., R25), and institutional career development awards (e.g., K12). For non-NRSA recipients, please refer to specific guidance on documenting the termination of appointments in the Funding Opportunity Announcement, and in the terms and conditions of the Notice of Award.

All KirschsteinNRSA Recipients

(1) The attached Termination Notice (PHS 416-7) serves as the official record of your training under a KirschsteinNRSA. This summary of work accomplished, support period, stipends received, and post-training activity is required of all recipients immediately after termination. After securing proper signatures, forward the completed form to the appropriate awarding office (National Institutes of Health (NIH) Institute or Center or Agency for Healthcare Research and Quality (AHRQ)). This form may be filled out online and then printed for submission.

(2) Because the sponsoring Federal agencies are asked periodically to review KirschsteinNRSA program impact in terms of career choices, you may be contacted after the termination of this award, but no more frequently than once every 2 years, to determine how the training obtained has influenced your career.

KirschsteinNRSA Postdoctoral Recipients with a Payback Obligation

(1) As specified in the Payback Agreement you signed at the time of award, biomedical or behavioral health-related research, health-related teaching, and/or health-related activities must begin within 2 years of terminating KirschsteinNRSA support; otherwise, unless an extension of the 2 year service initiation period or a waiver of the obligation is granted, financial payback becomes due. Further details are given in the Payback Agreement and the National Research Service Awards section of the most recent version of the NIH Grants Policy Statement found at: http://grants.nih.gov/grants/policy/policy.htm. If you have any questions, contact the awarding office that supported your training.

(2) To record your payback status and service, you will receive from the sponsoring Federal agency an Annual Payback Activities Certification (APAC) (PHS 6031-1) form one year after your termination date and annually thereafter until your service obligation has been completed.

(3) You are required to keep the Federal funding agency informed of your current address and telephone number until your total payback obligation is satisfied. Report any change to the NRSA Payback Service Center, Office of Extramural Programs, National Institutes of Health, 6011 Executive Boulevard, Suite 206, MSC 7650, Bethesda, MD 20892-7650; (301) 594-1835; (866) 298-9371.

Specific Instructions for Items on the Termination Notice

(Item 1) Where applicable, include in parentheses any maiden name or other name used. This information is helpful in identifying past records and publications.

(Item 2) Provide the complete grant or award number of the budget period supporting your last year of research training, career development or education (e.g., 5 T32 GM 60654-08).

(Item 3) Self-explanatory.

(Item 4) The last four digits of your Social Security Number are requested under authority of the Public Health Service Act as amended (42 USC 288). This information provides the sponsoring Federal agency with vital information necessary for accurate identification and review of terminated appointments and fellowships and, where applicable, to establish and maintain an accurate payback record file. Providing this portion of your Social Security Number is voluntary and you will not be deprived of any Federal rights, benefits, or privileges for refusing to disclose it.

(Item 5) Include the degree(s) sought or earned during the period of support and the date all degree(s) requirements were (or will be) completed.

(Item 6) Self-explanatory.

(Item 7) For Kirschstein-NRSA Awards Only -- Provide information on your total KirschsteinNRSA stipend support under the parent fellowship or training grant of which the number in Item 2 is a part. For domestic non-Federal institutions, the “Amount of Stipend” column must reflect the stipend only. Individual fellows sponsored by (training at) Federal or foreign institutions must include all money paid directly to them by government check in the “Amount of Stipend” column. Note the stipend amount must reflect only the Kirschstein-NRSA stipend. Do not include any supplementation provided by other sources. Do not include any other NRSA-awarded costs such as tuition or institutional allowance.

(Item 8) Self-explanatory.

(Item 9a) Please mark a single box under each of the three categories that best describes your anticipated post-award position, activity, and the organization with which you will be affiliated.

(Items 9b and 9c) Provide post-award title, address, and phone number, if known.

(Item 10) For Kirschstein-NRSA Awards Only -- Provide an address where information regarding post-KirschsteinNRSA training may be sent.

(Item 11) For Kirschstein-NRSA Awards Only -- Provide information on prior support from other KirschsteinNRSA grants and awards and/or National Health Service Corps (NHSC) scholarships for which you still have a service obligation. If you are currently participating in the NIH Loan Repayment Program, check “LRP.” This information will be used to develop a complete service obligation record.

(Item 12) In signing this form, I certify that the statements therein are true and complete to the best of my knowledge. Willful provision of false information is a criminal offense (U.S. Code, Title 18, Section 1001). I am aware that any false, fictitious, or fraudulent statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud and Civil Remedies Act of 1986 (45 CFR Part 79). Also, if I have a payback obligation, I understand that payback service must begin within 2 years of terminating my KirschsteinNRSA support; otherwise, financial payback becomes due, unless an extension of the 2-year service initiation period or a waiver of the obligation is granted. I also understand that if I fail to repay both principal and interest, the Federal Government will take authorized actions to collect the debt.

(Item 13) The sponsor of (for individual fellowship awards) or the contact Program Director (for an institutional award) must sign and date the form certifying that the research training information is correct.

(Item 14) For Kirschstein-NRSA Awards Only -- A business official of domestic non-Federal sponsoring institutions (with the knowledge and authority to verify this information) must certify that the information provided in Items 6 and 7 is correct according to institutional records.

NIH estimates that it will take 30 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 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.

Form Approved Through 06/30/2015 OMB No. 0925-0002

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

1. NAME OF FELLOW OR APPOINTEE (Last, first, middle)      

2. GRANT NO.      

3. NAME OF SPONSORING INSTITUTION      

4. SOCIAL SECURITY NO. XXX-XX-    

5. DEGREE(S) EARNED/ COMPLETION DATE(S)      

6. DATES OF SUPPORT UNDER THIS AWARD (Month, day, year):

FROM:      

TO:      

7. TOTAL KIRSCHSTEIN-NRSA STIPEND RECEIVED AND NUMBER OF MONTHS SUPPORTED UNDER THIS AWARD (See specific instructions for Amount of Stipend)

YEAR OF SUPPORT

AMOUNT OF STIPEND

NUMBER OF Months Days

YEAR OF SUPPORT

AMOUNT OF STIPEND

NUMBER OF Months Days

1ST YEAR

     

     

     

5TH YEAR

     

     

     

2ND YEAR

     

     

     

6TH YEAR

     

     

     

3RD YEAR

     

     

     

7TH YEAR

     

     

     

4TH YEAR

     

     

     

TOTALS

     

     

     

8. Provide a summary of training received and research undertaken during fellowship or trainee tenure. List publications, if any, resulting from the research during this period. List grants and career awards pending and received. If fellowship or training appointment is being terminated early, state reason.      

9a. POST-AWARD INFORMATION: Please mark a single box in each of the categories below.

9b. POST-AWARD POSITION TITLE, FIELD, NAME OF ORGANIZATION, CITY, AND STATE      

Type of Position

Activity

Organization

Student Resident/Clinical Fellow Postdoctoral Researcher Research Scientist (non-faculty) Faculty: Tenure-Track Faculty: Other Clinical Staff/Private Practice Unknown Other:      

Further Education/Training Teaching Research Administration Clinical Practice Unknown Other:      

Academic Industry Government Hospital Non-profit Unknown Other:      

9c. TEL NO.      

10a. MAILING ADDRESS AFTER TERMINATION OF THIS KIRSCHSTEIN-NRSA SUPPORT (Street, city, state, zip code)      

11. OTHER PHS SERVICE OBLIGATION SUPPORT

NHSC Scholarship: No of months:

     

Kirschstein-NRSA: No. of months:

     

Period of support:

     

10b. TEL NO.      

Grant No.:

     

E-MAIL:      

LRP

12. SIGNATURE OF FELLOW OR APPOINTEE (See specific instructions)

DATE      

13. Certification of Sponsor or Program Director: that to the best of my knowledge all the above information is correct.

SIGNATURE

DATE      

TYPED NAME OF SPONSOR OR PROGRAM DIRECTOR      

14. Business Official’s Verification of Items 6 and 7. (Not applicable to individual fellows at Federal or foreign institutions.)

SIGNATURE

DATE      

TYPED NAME OF BUSINESS OFFICIAL      

TEL:

     

FAX::

     

15. (For Government use only) The information provided in Items 6 and 7 is in agreement with PHS records.

SIGNATURE

DATE      

TYPED NAME AND AWARDING OFFICE      

PHS 416-7 (Rev. 6/12)

Privacy Act Statement.   The NIH maintains application and grant records as part of a system of records as defined by the Privacy Act:  NIH 09-25-0036, Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contract Information (DCIS), and Cooperative Agreement Information, HHS/NIH:  http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm.

PHS 416-7 (Rev. 6/12) Instructions