6349 Research Misconduct

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service

FORM APPROVED: OMB No. 0937-0198; Expires: 05/31/2020
See Statement of Burden on Reverse

INSTITUTIONAL ASSURANCE
AND
ANNUAL REPORT ON
POSSIBLE RESEARCH MISCONDUCT

Period Covered by this Report

January 1, 2020 to December 31, 2020
INSTITUTIONAL OFFICIAL'S NAME

Please make any mailing changes in the space to the right:

INSTITUTIONAL OFFICIAL'S TITLE

NAME OF INSTITUTION

MAILING ADDRESS OF INSTITUTIONAL OFFICIAL

Place mailing label here.

Section I. Administrative Policy
Each institution which receives or applies for a PHS research, research-training or research-related grant or cooperative agreement must have established
an administrative policy for responding to allegations of research misconduct that complies with the PHS regulation (42 CFR Part 93) and certify that it will
comply with that policy. This regulation does not cover regulated research under the jurisdiction of the Food and Drug Administration (FDA).

.

Has your institution established the administrative policy for responding to allegations of research misconduct required by the PHS regulation?
Yes (Please attach your institutional policy and procedures with this form. )

No

Section II. Types of Misconduct Activity Related to PHS Applications and Awards
A.

PLEASE CHECK THE BOX (to the left) if your institution has NOT received any allegations or conducted any inquiries or investigations of
allegations during the reporting period that (1) fall under the PHS definition of research misconduct and (2) involve receipt of or requests
for PHS funding, then complete Section III. Otherwise, please complete Section II.

B.

Please provide the requested information for each incident of alleged misconduct that involved a request for or receipt of PHS funds that fell within
the PHS definition of research misconduct. Please note that, in accordance with section 93.310(b), all investigations are to be reported to the Office
of Research Integrity (ORI) before or immediately upon commencement of the investigation.

PLEASE NOTE: For each incident of alleged research misconduct resulting in an allegation, inquiry, and/or investigation at your institution:
(1) provide the ORI case number, if assigned; (2) check the type of activity (allegation, inquiry, and/or investigation -- may include more than
one activity type for each reported incident); and (3) check the type of misconduct involved with each activity (may include more than one
type of misconduct). Attach a separate sheet if additional space or clarification is required.
Do NOT include any alleged fiscal misconduct, human or animal subject abuses, conflicts of interest, or violations of FDA regulated
research. If there is a research misconduct case involving foreign influence please notify the NIH funding official.
1. Activity continued into 2020:
Your Institution's
Unique Case
Identifier: (if
applicable)
1. ________

2. ________

3. ________

Incident
Number
1.

2.

3.

ORI Case Number,
if assigned:

Type of Activity
Inquiry . . . . . . . . . . .

Misconduct activity in conjunction with
another federal agency (if applicable)
Agency"s
Type of
Type of
Type of
Unique
Misconduct: Misconduct: Misconduct: Agency Name (e.g. Case
Fabrication Falsification Plagiarism NSF, DOD, VA, etc.): Identifier
______
__________

Investigation . . . . . .

__________

______

Inquiry . . . . . . . . . . .

__________

______

Investigation . . . . . .

__________

______

Inquiry . . . . . . . . . . .

__________

______

Investigation . . . . . .

__________

______

Continued on back
PHS-6349
Rev. 11/20

(Front)

PSC Publishing Services (301) 443-6740 EF

Section II. (Continued)
B.

(Continued)

Misconduct activity in
conjunction with another
federal agency (if applicable)

2. Activity begun in 2020:
Your Institution's
Unique Case
Identifier:(if
applicable)

Incident
Number

1. ________

2. ________

ORI Case Number,
if assigned:

1.

2.

_______
__

3. ________

3.

Type of Activity

Agency's Unique
Type of
Type of
Type of Agency Type
Misconduct: Misconduct: Misconduct: (e.g., NSF, DOD, Case
Identifier:
Fabrication Falsification Plagiarism VA, etc.):

Allegation . . . . . . . .

______________

______

Inquiry . . . . . . . . . . .

______________

______

Investigation . . . . . .

______________

______

Allegation . . . . . . . .

______________

______

Inquiry . . . . . . . . . . .

______________

______

Investigation . . . . . .

______________

______

Allegation . . . . . . . .

______________

______

Inquiry . . . . . . . . . . .

______________

______

Investigation . . . . . .

_______________

______

Section III: Who at your institution administers the written policies and procedures for addressing allegations of research misconduct that meet the
requirements of this part (42 CFR 93.300)? At some institutions this person is known as the Research Integrity Officer (RIO).
Prefix: _____NAME OF RESEARCH INTEGRITY OFFICER (RIO), Suffix: _____ (Please type):
TELEPHONE NUMBER:
(
)

-

FAX NUMBER:
(
)

-

E-MAIL ADDRESS OF RIO:

Section IV: Who is responsible for assuring that your institution fosters a research environment that promotes the responsible conduct of research
and discourages research misconduct (93.300 (c))? At some institutions this is the person with overall responsibility for administering the Responsible
Conduct of Research (RCR) program.
Prefix: _____NAME OF RCR COORDINATOR Suffix: _____ (Please type):
TELEPHONE NUMBER:
(
)

-

FAX NUMBER:
(
)

-

E-MAIL ADDRESS OF RCR COORDINATOR:

Section V. Certification
Official Certifying for Institution:
Prefix: _____NAME OF OFFICIAL Suffix: _____ (Please type)

TITLE

SIGNATURE

DATE

TELEPHONE NUMBER
(
)

-

FAX NUMBER
(
)

-

E-MAIL ADDRESS OF OFFICIAL:

STATEMENT OF BURDEN

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either of these addresses.
PHS-6349
Rev. 11/20

(Back)

Robin Parker
Assurance Program
Office of Research Integrity
1101 Wootton Parkway, Suite 240
Rockville, MD 20852
Phone: (240) 453-8407
E-Mail: [email protected]