PHS-6349 Institutional Assurance and Annual Report on Possible Re

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved
OMB No. 0937-0198; Expires:
See Statement of Burden on Reverse

Public Health Service

INSTITUTIONAL ASSURANCE
AND ANNUAL REPORT ON POSSIBLE
RESEARCH MISCONDUCT
Please make any mailing changes in the space to the right ☛

Period Covered by this Report
January 1, 2022 to December 31, 2022
INSTITUTIONAL OFFICIAL’S NAME
INSTITUTIONAL OFFICIAL’S TITLE
NAME OF INSTITUTION

Place mailing label here.

MAILING ADDRESS OF INSTITUTIONAL OFFICIAL

SECTION I. ADMINISTRATIVE POLICY
Has your institution established written policies and procedures for inquiring into and investigating allegations of research misconduct
as required by the Public Health Service Policies on Research Misconduct (42 CFR Part 93)?
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 2022:

Your Institution’s
Unique Case
Identifier: (if
applicable)

Incident
Number

1.

2.

3.

ORI Case Number,
if assigned:

Type of Activity

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

Inquiry
Investigation
Inquiry
Investigation
Inquiry
Investigation

(continued on next page)

PHS-6349 (Rev. 02/23)

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PSC Publishing Services (301) 443-6740

EF

SECTION II.B (CONTINUED)
2. Activity begun in 2022:

Your Institution’s
Unique Case
Identifier: (if
applicable)

Incident
Number

ORI Case Number,
if assigned:

Type of Activity

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

Allegation
1.

Inquiry
Investigation
Allegation

2.

Inquiry
Investigation
Allegation

3.

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 OFFICIAL

TELEPHONE NUMBER
(
)
-

SUFFIX
FAX NUMBER
(
)

E-MAIL ADDRESS OF OFFICIAL

-

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 OFFICIAL

TELEPHONE NUMBER
(
)
-

SUFFIX
FAX NUMBER
(
)

E-MAIL ADDRESS OF OFFICIAL

-

SECTION V. CERTIFICATION
OFFICIAL CERTIFYING FOR INSTITUTION
PREFIX

NAME OF OFFICIAL

SUFFIX

TITLE

SIGNATURE
TELEPHONE NUMBER
(
)
-

DATE (mm/dd/yyyy)
FAX NUMBER
(
)

-

E-MAIL ADDRESS OF OFFICIAL

STATEMENT OF BURDEN

RETURN THIS FORM TO:

Public reporting burden for this collection of information is estimated to average 10 minutes to
complete the form, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to: OS Reports Clearance Officer,
Hubert H. Humphrey Building, Room 503-H, 200 Independence Avenue, S.W., Washington,
D.C. 20201 (Attn: PRA) and to: Office of Management and Budget, Paperwork Reduction
Project (0937-0198) Washington, D.C. 20502. Please do not return this form to either of
these addresses.

PHS-6349 (Rev. 02/23)

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