Form 2 PHS 6031-1

Form Approved Through 08/31/2015 OMB No. 0925-0002

Department of Health and Human Services – Public Health Service Ruth L. Kirschstein National Research Service Award Annual Payback Activities Certification (APAC) See instructions and Privacy Act information in transmittal letter. Please complete applicable sections. This form can also be downloaded from http://grants.nih.gov/grants/forms.htm#training. Retain a copy for your files.

Section III – Employment Information When Engaged in Payback

NAME AND ADDRESS OF EMPLOYING ORGANIZATION      

NAME OF PAYBACK SERVICE SUPERVISOR      

TITLE      

Section I – Payback Status (Check applicable blocks[s])

SIGNATURE OF PAYBACK SERVICE SUPERVISOR

DATE

     

1.

Have not engaged in payback service during reporting period. (Complete Section IV.)

I certify that all of the above statements are true, complete, and correct to the best of my knowledge. (A willfully false certification is a criminal offense. U.S. Code, Title 18, Section 1001.) If supervisor is retired or deceased or if you, the recipient, are self-employed, provide notarized statement that reported employment information is accurate.

2.

Have elected to engage in financial payback. (Complete Section IV.)

3.

Request a12 month extension period to initiate payback service or a break in service. Also check this box if you need an extension to participate in any of the NIH Loan Repayment Programs. Specify the need for the extension under Section II, Item 4. (Complete Section IV.)

Section IV – Recipient Name and Address

NAME AND ADDRESS      

4.

Have been engaged in continuous payback service during reporting period. (Complete Sections II, III, and IV.)

Section II – Payback Service Description

1.

Number of months engaged in payback during this reporting period:

     

Section V – Certification of Kirschstein-NRSA Recipient

Dates: (mm/dd/yyyy – mm/dd/yyyy)

     

I certify that all of the above statements are true, complete, and correct to the best of my knowledge. (A willfully false certification is a criminal offense. U.S. Code, Title 18, Section 1001).

2.

Position Title :

     

SIGNATURE

DATE

     

3.

Payback Service

SOCIAL SECURITY NO. XXX-XX-    

DAYTIME TELEPHONE NO.      

E-MAIL      

a.

Full-time position with biomedical or behavioral health-related research, health-related teaching, and/or health-related activities as primary activity.

b.

Other position(s) where biomedical or behavioral health-related research, health-related teaching, and/or health-related activities averages at least 20 hours per week of a full work year.

Section VI – Acceptance by PHS Official (leave blank)

4.

Description of a) health-related research/teaching activities; b) field of research/training duties; and c) source of salary support. Include numbers of hours per week if not full time.

NAME AND TITLE OF PHS OFFICIAL      

Extension date payback service to begin or resume

Number of months of acceptable service this reporting period

a.

     

     

     

b.

     

c.

     

SIGNATURE

DATE

     

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
National Institutes of Health
Bethesda, MD 20892

To: Former Ruth L. Kirschstein National Research Service Awardees

Payback Requirements

Under Section 487 of the Public Health Service (PHS) Act as amended (42 USC 288), all individuals other than prebaccalaureate students who received a Ruth L. Kirschstein National Research Service Award (NRSA) prior to June 10, 1993, must engage in biomedical or behavioral health-related research and/or health-related teaching for a period equal to the period of Kirschstein-NRSA support in excess of 12 months.*

For Kirschstein-NRSA recipients who began appointments to training grants or activated fellowship awards on or after June 10, 1993, only the first twelve months of postdoctoral support will incur a service payback obligation. Such individuals may satisfy that obligation by engaging in an equal period of health-related research, health-related teaching, or health-related activities or by receiving an equal period of Kirschstein-NRSA supported postdoctoral research training. Kirschstein-NRSA postdoctoral support beyond the initial 12 months may also be used to satisfy a postdoctoral service obligation incurred for awards which began before June 10, 1993.

By regulation (42 CFR Part 66), this service must be initiated within two years after termination of Kirschstein-NRSA support. If payback service is not started within the 2-year period, financial payback will become due unless an extension of the period of undertaking payback or a waiver request has been approved by the PHS.

Annual Payback Activities Certification, Form PHS 6031-1

The enclosed Annual Payback Activities Certification (APAC) form is the basic communication between former Kirschstein-NRSA recipients and the PHS. Regardless of the nature of your present activities, complete and return the form. Do not hesitate to provide supplemental information or request clarification of your obligation from the PHS agency that supported your training.

Special Instructions for APAC

Follow the instructions on the APAC form together with these instructions. This form may be filled out online and printed for submission to PHS. It also may be downloaded, printed, and completed. If you need more than one form to cover the reporting period, duplicate the form and clearly label them at the top “#1 of 2 certifications,” etc. This form is available at: http://grants.nih.gov/grants/ forms.htm #training.

Section I

Item 1. Not Engaged: If this APAC is received in the first year after the termination of your Kirschstein-NRSA support and you are not electing financial payback or requesting an extension of the 2-year period in which to initiate payback, sign and return the form; no further information is required. If the APAC covers the second year after termination of your Kirschstein-NRSA support, financial payback will be due 24 months after the termination date unless a request for an extension of the payback initiation period or a payback waiver is submitted and approved.

Item 2. Financial Payback: Those electing financial payback will be contacted by the PHS with appropriate instructions.

Item 3. Extension: Reasons for an extension or break in service include such things as physicians completing residency training, graduate students completing degree requirements, temporary disability or substantial hardship. This item should also be used to report participation in any of the NIH Loan Repayment Programs (LRP). Participation in LRP will result in a deferral of the NRSA obligation because concurrent payback under both LRP and NRSA is not permissible. If requesting an extension because of LRP participation, include the start and end date of your LRP in Section II.4.

Item 4. Engaged in Payback Service: This item includes regular payback service (biomedical or behavioral health-related research, teaching, and/or activities). For additional information on acceptable payback service, see the Payback section of the most recent version of the NIH Grants Policy Statement found at http://grants.nih.gov/grants/policy/policy.htm.

Section II

Item 1. Number of Months: Indicate the number of months and dates (mm/dd/yyyy) engaged in payback service during this reporting period. Do not include any service already reported on previous APACs submitted.

Item 4. Description of Duties: The description of regular service should include sufficient information to serve as the basis for determination of acceptability. It should include: (a) the specific activities (research, teaching, health-related activities, etc.); (b) field of research/training duties; and (c) the source(s) of salary supporting the activities. Include number of hours per week if not full time and the dates covered by each activity, if different from those in Section II, Item 1.

Section III

This section must be completed and signed by the supervisor(s) of record.

Section V

For those engaged in payback service, the APAC should be signed on or after the end date reported in Section II, Item 1. The PHS requests the last four digits of the Social Security Number in order to maintain accurate payback records for former Kirschstein-NRSA trainees and fellows and is authorized to collect this information under Section 487 of the Public Health Service Act. Providing your Social Security Number is voluntary and you will not be deprived of any Federal rights, benefits or privileges for refusing to disclose it.

Preprinted Information

Address Verification: Until your payback obligation is completed, report immediately any change in name or address to the Kirschstein-NRSA Payback Service Center.

Reporting Period: Report only those activities occurring within the time period shown on the form. The APAC form is forwarded annually by the PHS until the payback obligation is complete.

Record of Payback Obligation: The legislative allowance, when applicable, reflects the individual’s initial 12 months of support under the Kirschstein-NRSA funding authority which on appointments or fellowship awards started prior to June 10, 1993, was not subject to payback.* Service credited is obtained from previous APAC reports.

Mailing/E-Mail

Return the completed APAC(s) with the necessary signatures, and one copy of any attachment(s), no later than 30 days after the reporting period end date to the address below. This item may also be sent via e-mail to the address listed below. When the payback service or extension request is approved by PHS, a copy of the APAC will be returned to you.

For any questions, please contact:

NRSA Payback Service Center

Office of Extramural Programs

OER/OD/National Institutes of Health

6011 Executive Boulevard, Suite 206, MSC 7650

Bethesda, MD 20892-7650

Phone: (301) 594-1835 or (866) 298-9371

[email protected]

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 (0925-0002). Do not return the completed form to this address.

* Individuals in delinquent payback status prior to August 13, 1981, have a payback obligation for the total amount of time of Kirschstein-NRSA support.

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 6031-1 (Rev. 08/12)