Form 23 UGSP Deferment

Last Updated – 12 August 2020

OMB Clearance Number: 0925-0299
Expiration Date: 30-June-2022

Academic Enrollment Certification and Service Obligation Deferment Request
Undergraduate Scholarship Program (UGSP)
National Institutes of Health NIH)
U.S. Department of Health and Human Services (DHHS)
Applicant’s Instructions – Please complete
Section A. Give this form to the Registrar’s
Office at the school at which you are enrolled
starting September 2018.

Academic Institution’s Instructions – Please complete Section B and return the form by mail to
National Institutes of Health Undergraduate Scholarship Program, 2 Center Drive / Room 2E26
(MSC 0230), Bethesda, Maryland 20892-0230. Or fax to 301-594-9606. If you have any
questions, call 301-451-4578 or e-mail Dr. Virginia Meyer at [email protected]

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 complete clinical training (describe)___________________________________________________________________________.
¨ 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
meets all the eligibility requirements on this form.
Items (1) and (2) of this section must be completed. The school may attach its own enrollment certification report listing the required information in
lieu of completing this section.
Certification of Academic Institution Registrar’s Office or Training Program Authorizing Official
The student / trainee:
(1) Is / was enrolled full-time during the academic period (MM-DD-YYYY)_______________ to (MM-DD-YYYY)_______________.
(2) Is / was participating in a clinical training program from (MM-DD-YYYY)_______________ to (MM-DD-YYYY)_______________.
(3) 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 / Institution________________________________________________________________________________________________
Authorizing Official / Financial Aid Administrator’s Name (please print)______________________________________________________________
Authorizing Official / Financial Aid Administrator’s Title (please print)________________________________________________________________
Signature______________________________________________________________________________Date____________________________
Telephone____________________Fax Number____________________Email Address________________________________________________
Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no
penalties for not participating or withdrawing from the study at any time. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any
report of the study. Information provided will be combined for all participants and reported as summaries.
Public reporting burden for this collection of information is estimated to average 8 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 (0925-0299). Do not return the completed form to this address.

NIH 2762-3

Last Updated – 31-August-2018

OMB Clearance Number: 0925-0299
Expiration Date: 30-June-2019

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 Completing CLINICAL TRAINING.
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 your contract with the NIH.
Authorized Certifying Official
n Registrar or authorized school official or designee.

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are
protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the
study at any time. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers
will not appear in any report of the study. Information provided will be combined for all participants and reported as summaries.

NIH 2762-3