Phs 2271

Instructions for PHS 2271 Form Approved Through 03/31/2020

Revised 08/2018 OMB No. 0925-0002

U.S. Department of Health and Human Services
Public Health Service

Information and Instructions for Completing
Statement of Appointment (Form PHS 2271)

Public reporting burden for this collection of information is estimated to average 15 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.

I. INTRODUCTION

This form is to be used to appoint individuals as trainees to institutional Ruth L. Kirschstein-National Service Research Award (Kirschstein-NRSA) programs (e.g., T32, T34, T35) and applicable non-NRSA individual and institutional research training programs (e.g., the NIH intramural research training award program and T15 training grants). It can also be used to document the appointment of scholars to institutional career development awards (e.g., K12) and individual participants to research education awards (e.g., R25).

Please read carefully the following instructions, including the Privacy Act Statement at the end of this document. All items on the form must be completed unless otherwise indicated in these instructions.

II. GENERAL INSTRUCTIONS

A. Definitions:

Types of Awards

Kirschstein-NRSA. Awards that provide undergraduate, predoctoral, and postdoctoral research training support under the authority of Section 487 of the PHS Act (42 USC 288). All Kirschstein-NRSA trainees must meet specific citizenship requirements – for details, see Item 8.

Non-NRSA Research Training. Awards that provide predoctoral and postdoctoral research training support through non-NRSA funding authorities. These training programs may or may not have the same provisions and requirements as Kirschstein-NRSA awards (e.g., specific citizenship requirements).

Career Development. Awards that provide doctoral-level investigators an opportunity to enhance their research careers. Individuals appointed to institutional career development awards must meet specific citizenship requirements—for details, see Item 8.

Research Education. Awards that provide support for programs intended to attract investigators to a specific field of study. Individuals appointed to research education award programs may or may not be subject to specific citizenship requirements—for details, see Item 8.

Types of Appointments

Trainee. A person appointed to and supported by an institutional Kirschstein-NRSA or non-NRSA research training award.

Scholar. A person appointed to and supported by an institutional career development award.

Participant. A person appointed to and supported by a research education award.

B. Application

A “Statement of Appointment” form covers the support of an individual for a particular budget period and is required for each new appointment, reappointment, or amended appointment of an individual receiving stipend, tuition costs, or travel expenses as a trainee under a Kirschstein-NRSA or other applicable PHS institutional training grant. This form may also be used to document the salary and other support provided to an individual as a scholar or participant under a career development or research education program award in which the institution selects and appoints the individual. The form (which is signed by both the individual and the Program Director) must be completed and submitted to PHS at the time the individual starts the appointment or reappointment, or, in the case of an amendment, as soon as the change occurs. If there are multiple Program Directors on the award, the contact PD should sign.

For new postdoctoral trainees appointed to Kirschstein-NRSA institutional grants, a signed and dated payback agreement must be submitted with this appointment form before a stipend or other allowance may be paid.

C. Submission

The original should be sent to the awarding component. A copy should also be given to the trainee, scholar, or participant, the Program Director, and Business Official.

III. ITEM-BY-ITEM INSTRUCTIONS

Item 1. PHS Grant Number. Insert the entire PHS Grant Number as shown on the particular Notice of Grant Award from which funds are provided, e.g., 5 T32 GM12453-03 would be listed as
Type: 5; Activity Code: T32; ID Serial Number: GM12453-03.

Item 2. Trainee/Scholar/Participant Name. Self-explanatory.

Item 3. Sex. Self-explanatory.

Item 4. Type of Action.

New Appointment: When an individual has not been previously supported by this grant.

Reappointment: When an individual was supported by this grant during a previous budget period, the appointment covered by this form is designated a reappointment. Skip the shaded items if the information provided will be the same as that reported during the prior budget period. Always complete the non-shaded items.

Amendment: “Amendment” pertains only to a change of item 15 (Appointment Period); or 20 (Support from this Grant) during a period of appointment for which a “Statement of Appointment” form has already been submitted. Amendments must be submitted as soon as the change occurs. Complete only items 1, 2, 4, 6, 22, 23, and the item(s) to be amended.

Item 5. Prior NRSA Support. Provide information on support from any Kirschstein-NRSA grants and awards received prior to this grant year.

Item 6. Social Security Number. Trainees/scholars/participants are asked to voluntarily provide the last four digits of their Social Security Numbers. This information provides the agency with vital information necessary for accurate identification and review of appointments and for management of PHS grant programs. See the Privacy Act Statement at the end of these instructions for further information concerning this request.

Item 7. Birthdate. Self-explanatory.

Item 8. Citizenship. Check the box corresponding to the trainee’s, scholar’s, or participant’s citizenship and visa status. If not a U.S. citizen, list the country of citizenship.

A noncitizen national is an individual who, although not a citizen of the United States, owes permanent allegiance to the United States. Individuals in this category are generally born in lands which are not States, but which are under U.S. sovereignty, jurisdiction, or administration (e.g., American Samoa).

Kirschstein-NRSA trainees and institutional career development scholars must be U.S. citizens, non-citizen nationals, or permanent residents of the United States. Individuals on temporary or student visas are not eligible. Trainees or scholars in these programs who are permanent residents of the U.S. must submit a notary’s signed statement with this appointment form certifying that they have (1) a Permanent Resident Card (USCIS Form I-551), or (2) other legal verification of such status.

Trainees in non-NRSA research training programs and participants in research education award programs should consult the applicable Funding Opportunity Announcement (FOA) or the NIH intramural research training award program for citizenship requirements.

Item 9. ORCID Identifier (ID). Provide the ORCID ID assigned to the individual being appointed. During the electronic appointment process, a link to ORCID.org will allow trainees/scholars/participants to either create a new ORCID ID or associate their eRA Commons Personal Profile with an existing ORCID ID.

Item 10. Permanent Address. Provide mailing and e-mail addresses by which the appointed individual can be reached after completion of support from the program. (Do not give current addresses unless they are considered permanent as defined above.)

Items 11-14. Race/Ethnicity/Disability/Disadvantaged Background. Responses to these items will help provide statistical information on the participation of individuals from diverse groups in Public Health Service (PHS) programs and identify inequities in terms of recruitment and retention based on race, ethnicity, disability and/or disadvantaged background.

Trainees, scholars, and participants are strongly encouraged to provide this information, however declining to do so will in no way affect their appointments.

This information will be retained by the PHS in accordance with and protected by the Privacy Act of 1974. Racial/ethnic/disability/background data are confidential and all analyses utilizing the data will report aggregate statistical findings only and will not identify individuals. (See the Privacy Act Statement at the end of these instructions for more information.)

11. Are you Hispanic (or Latino)?

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino”.

12. What is your racial background?
Check one or more.

American Indian or Alaska Native. A person having origins in any of the original peoples of North, Central, or South America and maintains tribal affiliation or community.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

13. Do you have a disability?

Disability: A physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990, as amended.

14. Are you from a disadvantaged background?

Disadvantaged Background: An individual is considered to be from a disadvantaged background if he or she meets two or more of the following criteria:

1. Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Definition: );https://nche.ed.gov/mckinney-vento/

2. Were or currently are in the foster care system, as defined by the Administration for Children and Families (Definition: );https://www.acf.hhs.gov/cb/focus-areas/foster-care HYPERLINK "https://www.acf.hhs.gov/cb/focus-areas/foster-care" 

3. https://www.fns.usda.gov/school-meals/income-eligibility-guidelines HYPERLINK "https://www.fns.usda.gov/school-meals/income-eligibility-guidelines" 

4. https://nces.ed.gov/pubs2018/2018009.pdf HYPERLINK "https://nces.ed.gov/pubs2018/2018009.pdf" 

5. https://www2.ed.gov/programs/fpg/eligibility.html HYPERLINK "https://www2.ed.gov/programs/fpg/eligibility.html" 

6. https://www.fns.usda.gov/wic/wic-eligibility-requirements HYPERLINK "https://www.fns.usda.gov/wic/wic-eligibility-requirements" 

7. rs for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage AreasCente HYPERLINK "https://www.qhpcertification.cms.gov/s/LowIncomeandHPSAZipCodeListingPY2020.xlsx?v=1" https://data.hrsa.gov/tools/rural-health HYPERLINK "https://data.hrsa.gov/tools/rural-health"

https://era.nih.gov/privacy-act-and-era.htm

     

     

     

     

     

    

     

     

     

     

 

  

  

  

     

     

FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Post-master’s  FORMCHECKBOX Graduate Student  FORMCHECKBOX  FORMCHECKBOX

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

						     
							     
 FORMTEXT
22. SUPPORT FOR PERIOD OF APPOINTMENT
TYPE			Total for this Grant (Omit cents)
Stipend / Salary / Other Compensation			$	     
TOTAL			$	     
23. STATEMENT OF NONDELINQUENCY ON U.S. FEDERAL DEBT. Is the appointee delinquent on the repayment of any U.S. Federal debt(s)?
NO YES (If “Yes,” please explain below.)
     
24. CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true and complete to the best of my knowledge and that I will comply with all applicable Public Health Service terms and conditions governing my appointment. I am aware that any false, fictitious or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.					(a) SIGNATURE OF APPOINTEE			(b) DATE
								     
25. This individual is qualified for this program and is eligible to receive financial support for the period specified above. A copy of this appointment form will be given to the individual.					(a) SIGNATURE OF PROGRAM DIRECTOR			(b) DATE
								     
(c) NAME OF PROGRAM DIRECTOR	     
(d) INSTITUTION’S NAME, ADDRESS, AND PHONE NO. (Street, city, state, zip code)
     

PHS 2271 (Rev. 06/15) Page 2 of 2

Specialty Boards

If applicable, select a single specialty or subspecialty to complete item 17. If more than one applies, select the one most closely related to the field of career development or research training for this appointment.

Allergy and Immunology

Allergy and Immunology

Anesthesiology

Anesthesiology (General)

Critical Care Medicine

Hospice and Palliative Medicine

Neurocritical Care

Pain Medicine

Pediatric Anesthesiology

Sleep Medicine

Colon and Rectal Surgery

Colon and Rectal Surgery

Dermatology

Dermatology (General)

Dermatopathology

Micrographic Dermatologic Surgery

Pediatric Dermatology

Dental

Dental Public Health

Endodontics

Oral and Maxillofacial Pathology

Oral and Maxillofacial Radiology

Oral and Maxillofacial Surgery

Orthodontics and Dentofacial Orthopedics

Pediatric Dentistry

Periodontics

Prosthodontics

Emergency Medicine

Emergency Medicine (General)

Anesthesiology Critical Care Medicine

Emergency Medical Services

Hospice and Palliative Medicine

Internal Medicine-Critical Care Medicine

Medical Toxicology

Neurocritical Care

Pain Medicine

Pediatric Emergency Medicine

Sports Medicine

Undersea and Hyperbaric Medicine

Family Medicine

Family Medicine (General)

Adolescent Medicine

Geriatric Medicine

Hospice and Palliative Medicine

Pain Medicine

Sleep Medicine

Sports Medicine

Internal Medicine

Internal Medicine (General)

Adolescent Medicine

Adult Congenital Heart Disease

Advanced Heart Failure and Transplant Cardiology

Cardiovascular Disease

Clinical Cardiac Electrophysiology

Critical Care Medicine

Endocrinology, Diabetes and Metabolism

Gastroenterology

Geriatric Medicine

Hematology

Hospice and Palliative Medicine

Infectious Disease

Interventional Cardiology

Medical Oncology

Nephrology

Pulmonary Disease

Rheumatology

Sleep Medicine

Sports Medicine

Transplant Hepatology

Medical Genetics and Genomics

Clinical Biochemical Genetics

Clinical Genetics and Genomics (M.D.)

Laboratory Genetics and Genomics

Medical Biochemical Genetics

Molecular Genetic Pathology

Neurological Surgery

Neurological Surgery (General)

Neurocritical Care

Nuclear Medicine

Nuclear Medicine

Obstetrics and Gynecology

Obstetrics and Gynecology (General)

Complex Family Planning

Critical Care Medicine

Female Pelvic Medicine and Reconstructive Surgery

Gynecologic Oncology

Hospice and Palliative Medicine

Maternal and Fetal Medicine

Reproductive Endocrinology and Infertility

Ophthalmology

Ophthalmology

Orthopedic Surgery

Orthopedic Surgery (General)

Orthopedic Sports Medicine

Surgery of the Hand

Otolaryngology

Otolaryngology (General)

Neurotology

Complex Pediatric Otolaryngology

Plastic Surgery Within the Head and Neck

Sleep Medicine

Pathology

Pathology - Anatomic/Pathology - Clinical

Pathology - Anatomic

Pathology - Clinical

Blood Banking/Transfusion Medicine

Clinical Informatics

Cytopathology

Dermatopathology

Hematopathology

Neuropathology

Pathology – Chemical

Pathology – Forensic

Pathology – Medical Microbiology

Pathology – Molecular Genetic

Pathology – Pediatric

Pediatrics

Pediatrics (General)

Adolescent Medicine

Child Abuse Pediatrics

Developmental-Behavioral Pediatrics

Hospice and Palliative Medicine

Medical Toxicology

Neonatal-Perinatal Medicine

Pediatric Cardiology

Pediatric Critical Care Medicine

Pediatric Emergency Medicine

Pediatric Endocrinology

Pediatric Gastroenterology

Pediatric Hematology-Oncology

Pediatric Hospital Medicine

Pediatric Infectious Diseases

Pediatric Nephrology

Pediatric Pulmonology

Pediatric Rheumatology

Pediatric Transplant Hepatology

Sleep Medicine

Sports Medicine

Physical Medicine and Rehabilitation

Physical Medicine and Rehabilitation (General)

Brain Injury Medicine

Hospice and Palliative Medicine

Neuromuscular Medicine

Pain Medicine

Pediatric Rehabilitation Medicine

Spinal Cord Injury Medicine

Sports Medicine

Plastic Surgery

Plastic Surgery (General)

Plastic Surgery Within the Head and Neck

Surgery of the Hand

Preventive Medicine

Addiction Medicine

Aerospace Medicine

Clinical Informatics

Medical Toxicology

Occupational Medicine

Public Health and General Preventive Medicine

Undersea and Hyperbaric Medicine

Psychiatry and Neurology

Neurology (General)

Psychiatry (General)

Addiction Psychiatry

Brain Injury Medicine

Child and Adolescent Psychiatry

Clinical Neurophysiology

Consultation-Liaison Psychiatry

Epilepsy

Forensic Psychiatry

Geriatric Psychiatry

Hospice and Palliative Medicine

Neurocritical Care

Neurodevelopmental Disabilities

Neurology with Special Qualification in Child Neurology

Neuromuscular Medicine

Pain Medicine

Sleep Medicine

Vascular Neurology

Radiology

Diagnostic Radiology

Hospice and Palliative Medicine

Interventional Radiology and Diagnostic Radiology

Medical Physics (Diagnostic, Nuclear, Therapeutic)

Neuroradiology

Nuclear Radiology

Pain Medicine

Pediatric Radiology

Radiation Oncology

Surgery

Surgery (General)

Complex General Surgical Oncology

Hospice and Palliative Medicine

Pediatric Surgery

Surgery of the Hand

Surgical Critical Care

Vascular Surgery

Thoracic Surgery

Thoracic and Cardiac Surgery (General)

Congenital Cardiac Surgery

Urology

Urology (General)

Female Pelvic Medicine and Reconstructive Surgery

Pediatric Urology

PHS 2271 (Rev. 08/18) — Instructions