Deferment Form

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OMB Clearance Number: 0925-0299
Expiration Date: 31 Mar 2027
Burden Time: 10 minutes

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 – Complete Section A. Give this form to the Registrar’s Office at the school at which you are enrolled starting Fall 2027.
Academic Institution’s Instructions – Complete Section B and return by one of these options:
Email: 	Dr. Moraima Matus-Nicodemos at [email protected]
Mail: 	Dr. Moraima Matus-Nicodemos
	NIH Undergraduate Scholarship Program
	2 Center Drive / Room 2E26 (MSC 0230)
	Bethesda, Maryland 20892. 
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	
    • 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. Completion of this collection form is voluntary and there are no penalties for not participating or withdrawing at any time. The collection information will be kept private to the extent provided by law. Information provided will be covered by the following SORNs: OPM/GOVT-1, OPM/GOVT-5, 09-90-0020, 09-25-0014, 09-25-0108, 09-25-0140, 09-25-0158, and 09-25-0165.

Public reporting burden for this collection of information is estimated to average 10 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.
Last Updated –22-Oct-2023	OMB Clearance Number: 0925-0299
Expiration Date: 31-Mar-2027
Burden Time: 10 minutes
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:

    • Enrolled full-time in an accredited MEDICAL SCHOOL.
    • Completing CLINICAL TRAINING.
    • Enrolled full-time in GRADUATE SCHOOL (doctoral-level programs only).

Scholars enrolled in an UNDERGRADUATE DEGREE PROGRAM, please note:
    • 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
    • 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. Completion of this collection form is voluntary and there are no penalties for not participating or withdrawing at any time. The collection information will be kept private to the extent provided by law. Information provided will be covered by the following SORNs: OPM/GOVT-1, OPM/GOVT-5, 09-90-0020, 09-25-0014, 09-25-0108, 09-25-0140, 09-25-0158, and 09-25-0165.

Public reporting burden for this collection of information is estimated to average 10 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.