Form 14 Deferment Form

Last Updated – February 21, 2013

OMB No. 0925-0299
Form approved for use through 03/31/2014

U.S. Department of Health and Human Services
National Institutes of Health
Undergraduate Scholarship Program (UGSP) – Academic Enrollment Certification and Service Obligation Deferment Request
Applicant’s Instructions – Please complete Section A. Academic Institution’s Instructions – Please complete Section B and return to mail to
Give this form to the Registrar’s Office at the school at
the National Institutes of Health Undergraduate Scholarship Program, 2 Center Drive,
which you are enrolled starting September 2013.
Room 2W11A (MSC 0230), Bethesda, Maryland 20892-0230 OR fax 301-594-9606 OR
email a scanned copy to Mrs. Lizette Camacho at [email protected]. Call 301443-8215 if you have any questions or concerns.
Section A – The applicant completes this section.
1. Applicant’s Name (last, first, middle)

1a. Other Names Used on Official Documents (last, first, middle)

2. Student Identification Number
3. NIH Badge Number (completed by UGSP office)
Check One:
¨ I am enrolled full-time in an accredited Undergraduate Program. University Name__________________________________________________
OR
¨ I meet the qualifications for the deferment checked below and request that the NIH Undergraduate Scholarship Program defer my service
obligation for the academic period from _________________________ to _________________________.
¨ While I am enrolled full-time in an accredited MEDICAL SCHOOL.
¨ While I am enrolled full-time in an approved GRADUATE PROGRAM.
I authorize the institution indicated in Section B to release information about my academic enrollment to administrators of the NIH Undergraduate
Scholarship Program (UGSP) and to other authorized Government officials.
Signature (Sign your full name in ink)______________________________________________________________ Date______________________
Section B – To be completed by Academic Institution Registrar’s Office
I certify, to the best of my knowledge, that the student named above is/was engaged in the program indicated above, and that the student’s program
meet all the eligibility requirements on this form.
Items (1) and (2) of this section must be completed. The school may attach it’s own enrollment certification report listing the required information in
lieu of completing this section.
Certification of Academic Institution Registrar’s Office
The student:
(1) Is/was enrolled full-time during the academic period (MM-DD-YYYY)_______________ to (MM-DD-YYYY)_______________.
(2) Is reasonably expected to complete his/her program requirements on (MM-DD-YYYY)_______________.
The undersigned institutional representative certifies that, to the best of his/her knowledge, the information reported above is accurate. This
Certification should include the school’s seal or official stamp.
Name of School ________________________________________________________________________________________________________
Financial Aid Administrator’s Name (please print)_______________________________________Title____________________________________
Signature______________________________________________________________________________Date____________________________
Telephone____________________Fax Number____________________Email Address_______________________________________________
Public reporting burden for this collection of information is estimated to average 15-minutes per response, including the time for reviewing instructions. 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. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-0299). Do not return the completed form to this address.

NIH 2762-3

Last Updated – February 21, 2013

OMB No. 0925-0299
Form approved for use through 03/31/2014

Deferment Request Form – Reverse Side
A deferment is a period during which I have been approved to postpone my service obligation to the National Institutes of Health (NIH).
Deferment Eligibility Criteria:
I may defer (postpone) my service obligation while I am:
n Enrolled full-time in an accredited MEDICAL SCHOOL.
n Enrolled full-time in GRADUATE SCHOOL (doctoral-level programs only).
Scholars enrolled in an UNDERGRADUATE DEGREE PROGRAM, please note:
n Submission of this form certifies your continuing undergraduate enrollment. If you fail to submit this form, the Undergraduate
Scholarship Program (UGSP) will assume that you have withdrawn from your undergraduate degree program. Withdrawal from college
prior to graduation constitutes a breach of you contract with the NIH.
Authorized Certifying Official
n Registrar or authorized school official or designee.
Privacy Act Notice
The primary use of information collected via the Office of Intramural Training and Education (OITE) online forms is to evaluate an
applicant's qualifications for research training at the National Institutes of Health (NIH). Information may be used during admission
consideration; in preparing appointment paperwork; and to provide data for training program evaluation. Information will be disclosed
to investigators, members of advisory committees, OITE staff, and contractors working on our behalf. Additional disclosures may be
made to law enforcement agencies concerning violations of law or regulation. Application for this program is voluntary, however, in
order for the OITE to process an application, the applicant must complete the required fields.
The legal authority granted to NIH to train future biomedical scientists comes from several sources. Title 42 of the U.S. Code, Sections
241 and 282(b)(13) authorize the Director, NIH, to conduct and support research training for which fellowship support is not provided
under Part 487 of the Public Health Service (PHS) Act (i.e., National Research Service Awards), and that is not residency training of
physicians or other health professionals. Sections 405(b)(1)(C) of the PHS Act and 42 U.S.C. Sections 284(b)(1)(C)] and 285-287
grant this same authority to the Director of each of the Institutes/Centers at NIH.

NIH 2762-3