Form 1 HHS 568

Form Approved Through 06/30/2015

DEPARTMENT OF HEALTH AND HUMAN SERVICES

O
MB No. 0925-0002

Procedure for Submission of

Final Invention Statement and Certification (For Grant or Award)

Form HHS 568

A Final Invention Statement and Certification (Form HHS 568) shall be executed and submitted within 90 days following the expiration or termination of a grant or award. The Statement shall include all inventions which were conceived or first actually reduced to practice during the course of work under the grant or award, from the original effective date of support through the date of completion or termination. The Statement shall include any inventions reported previously for the grant or award as part of a non-competing application. This reporting requirement is applicable to grants and awards by Department of Health and Human Services in support of research.

The Final Invention Statement and Certification does not in any way relieve the person responsible for the grant or award, or the institution, of the obligation to assure that all inventions are promptly and fully reported directly to the National Institutes of Health, as required by terms of the grant or award. Information regarding the reporting of inventions, including the reporting form to be followed, may be obtained from the Office of Policy for Extramural Research Administration, Division of Extramural Inventions and Technology Resources, 6705 Rockledge Drive MSC 7980, Bethesda, Maryland 20892-7980, Telephone: (301) 435-1986.

The original of the completed Final Invention Statement and Certification is to be returned to the awarding component that funded the grant or award. The entire grant or award number must appear in the designated box on the form. The period covered by the Final Invention Statement is the project period of the grant or award at a particular grantee institution. If no inventions were involved, insert the word “None” in the first block under item Title of Invention. Each Statement requires the signature of an institution official authorized to sign on behalf of the institution.

The PHS estimates that it will take from 5 to 10 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 aspects of this collection of information, including suggestions for reducing this burden, send comments to: NIH, Project Clearance Office, 6701 Rockledge Drive MSC 7730, Bethesda, MD 20892-7730, ATTN: PRA (0925-0002). Do not send this form to these addresses; they are for comments only.

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.

							Form Approved Through 06/30/2015 OMB No. 0925-0002
Department of Health and Human Services Final Invention Statement and Certification (For Grant or Award)							DHHS Grant or Award No.      
 A. We hereby certify that, to the best of our knowledge and belief, all inventions are listed below which were conceived and/or first actually reduced to practice during the course of work under the above-referenced DHHS grant or award for the period
	     		through		     				.
	original effective date				date of termination
B. Inventions (Note: If no inventions have been made under the grant or award, insert the word “NONE” under Title below.)
NAME OF INVENTOR		TITLE OF INVENTION						DATE REPORTED TO DHHS
     		     						     
     		     						     
     		     						     
     		     						     
     		     						     
     		     						     
     		     						     
     		     						     
     		     						     
(Use continuation sheet if necessary)
C. Signature — This block must be signed by an official authorized to sign on behalf of the institution.
Title						Name and Mailing Address of Institution      
     
Typed Name      
Signature				Date      

HHS 568 (Rev. 06/12) — Instructions