Form 2 PHS 6031-1 FORMS-G

Form Approved Through 02/28/2023 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 block[s])

SIGNATURE OF PAYBACK SERVICE SUPERVISOR

DATE

     

1.

Have not engaged in payback service during reporting period. (Complete Sections IV and V.)

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 Sections IV and V.)

3.

Request a 12 month extension period to initiate payback service or a break in service. Specify the need for the extension under Section II, Item 4a. (Complete Sections IV and V.)

Section IV – Kirschstein NRSA Recipient Name and Address

NAME AND ADDRESS      

4.

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

5.

Request a waiver based on permanent and total disability or substantial hardship.  Request will not be considered until 24 months after NRSA termination; instructions for documentation will be provided after the request has been received. (Complete Sections IV and V.)

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

DAYTIME TELEPHONE NO.      

E-MAIL      

Position(s) where biomedical or behavioral health-related research, health-related research training, health-related teaching (or any combination thereof) 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/research training/teaching activities; b) field of research/research training/teaching 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

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 research training, or health-related teaching (or any combination thereof), or by receiving an equal period of continued Kirschstein-NRSA supported postdoctoral research training excluding any period of time in which the PHS has deferred the payback obligation (e.g. during concurrent participation in the NIH Loan Repayment Program).

By regulation (42 CFR Part 66), this service must be initiated within two years after termination of Kirschstein-NRSA support, unless the PHS extends (defers) the date in which the service must be initiated, or the PHS waives the service obligation. 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: https://grants.nih.gov/grants/forms/manage_fellow_and_trainees.htm.

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 payback waiver is submitted and subsequently approved after the 24 months.

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, completing degree requirements, temporary disability or substantial hardship.

Item 4. Engaged in Payback Service: This item includes regular payback service (biomedical or behavioral health-related research, health-related research training, health-related teaching, or any combination thereof). 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.

Item 5. Permanent and Total Disability or Substantial Hardship Waiver: Request should be submitted 24 months after NRSA termination. Instructions for additional documentation will be provided after request has been received.

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 (health-related research/research training/teaching or any combination thereof); (b) field of research/research training/teaching 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 IV

This is the NRSA recipient’s name and residential address.

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.

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, [email protected]

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: 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

Division of Loan Repayment

OER/OD/National Institutes of Health

6700B Rockledge Drive, Suite 2300, MSC 6904

Bethesda, MD 20892-6904

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.

Privacy Act Statement.  The NIH maintains application and grant records as part of a system of records defined by the Privacy Act: NIH 09-25-0225 https://era.nih.gov/privacy-act-and-era.htm.

PHS 6031-1 (Rev. 09/2020)