PHS 2271 (Rev. 08/12), Statement Of Training Appointment Phs2271
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Instructions for PHS 2271 Revised 03/2017 Form Approved Through 03/31/2020 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 nonNRSA 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 PHS 2271 (Rev. 06/15) — Instructions 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 nonNRSA 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 PHS 2271 (Rev. 06/15) — Instructions 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, noncitizen 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. 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 10-13. 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.) 10. 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”. 11. 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. PHS 2271 (Rev. 06/15) — Instructions 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. 12. 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. 13. Are you from a disadvantaged background? Applies to high school and undergraduate appointees only. Disadvantaged Background: An individual is considered to be from a disadvantaged background if he or she: 1. Comes from a family with an annual income below established low-income thresholds. These thresholds are based on family size, published by the U.S. Bureau of the Census; adjusted annually for changes in the Consumer Price Index; and adjusted by the Secretary for use in all health professions programs. The Secretary periodically publishes these income levels at http://aspe.hhs.gov/poverty/index.shtml. 2. Comes from an educational environment, such as that found in certain rural or inner-city environments, that has demonstrably and recently directly inhibited the acquisition of the knowledge, skills, and abilities necessary to develop and participate in a research career. Item 14. Field of Training (FOT). Provide a single numeric FOT code from the list below that best fits the research training that will be provided during the appointment. PHS 2271 (Rev. 06/15) — Instructions Item 15. Period of this Appointment. The period shown must always be 8 weeks or more and in most cases will be 12 months. Appointment periods may exceed 12 months in rare cases and only with prior approval from the PHS. Item 16. Education. List undergraduate, master’s, and doctoral degrees and the month and year earned. Item 17. Specialty Boards. If applicable, select a specialty from the attached list. If not applicable, indicate N/A. Items 18-19. Degrees Sought. Provide the degree sought under the award and the expected completion date (mm/yyyy). Indicate whether the appointee is in a dual degree program (e.g., M.D./Ph.D.). Appointees in dual-degree programs (e.g., M.D./Ph.D., D.D.D./Ph.D.) should report all degrees being sought. Item 20. Support for Period of Appointment. Indicate the total amount the appointee expects to receive from the grant during the appointment period. For trainees, provide the stipend amount. CDC trainees should provide the stipend amount, tuition/fees, and travel. For career development scholars and research education award participants, report only the salary or subsistence allowance to be received from the grant. Item 21. Statement of Nondelinquency on U.S. Federal Debt. A “Statement of Nondelinquency on Federal Debt” is required for each particular appointment period and is to be completed by each individual (trainee) appointed to receive financial support under a PHS institutional training grant. If the prospective trainee is delinquent on Federal debt, the PHS must review the explanation required to be provided on, or attached to, the form. In such case the PHS shall (a) take such information into account when determining whether the prospective trainee is responsible with respect to that appointment, and (b) consider not approving the appointment until payment is made or satisfactory arrangements are made with the agency to whom the debt is owed. Therefore, it may be necessary for the PHS to contact the prospective trainee before the appointment can be approved to confirm the status of the debt and ascertain the payment arrangements for its liquidation. Individuals failing to liquidate indebtedness to the Federal Government in a businesslike manner place themselves at risk of not receiving PHS financial assistance. The PHS awarding component shall notify the sponsoring institution in writing of its decision regarding the approval of a prospective appointee where this form discloses delinquency on Federal debt. The trainee must check the appropriate box. If the “Yes” box is checked, please provide an explanation in the space provided. The question applies only to the person requesting financial assistance, and does not apply to the person who signs the form as the Program Director. Examples of Federal Debt include delinquent taxes, audit disallowances, guaranteed or direct student loans, FHA loans, business loans, and other miscellaneous administrative debts. For purposes of this certification, the following definitions of “delinquency” apply: • For direct loans and fellowships (whether awarded directly to the applicant by the Federal Government or by an institution using Federal funds), a debt more than 31 days past due on a scheduled financial payment. (This definition excludes service payback under a National Research Service Award.) • For guaranteed and insured loans, recipients of a loan guaranteed by the Federal Government that the Federal Government has repurchased from a lender because the borrower breached the loan agreement and is in default. Item 22. Certification and Signature of Appointee. Self-explanatory. Item 23. Certification, Signature, and Address of Program Director. Self-explanatory. Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the Privacy Act: NIH 09-25-0036, Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contract Information (DCIS), and Cooperative Agreement Information, HHS/NIH: http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm. Form Approved Through 03/31/2020 OMB No. 0925-0002 Department of Health and Human Services Public Health Services Follow attached instructions carefully. Submit this form to the PHS awarding component at the time the individual is appointed, is reappointed, or the reported appointment is amended. For a new postdoctoral trainee under a KirschsteinNRSA award, a signed and dated payback agreement must accompany this form. Statement of Appointment (Please Type) 1. PHS GRANT NUMBER Type Activity ID Serial No. 3. SEX 2. APPOINTEE’S NAME (Last, first, initial) M F Do Not Wish to Provide 4. TYPE OF ACTION (Check only one type) 5. PRIOR NRSA SUPPORT (Individual or institutional) NO NEW appointment (NOT previously supported by this grant) YES (If “Yes,” see instructions) REAPPOINTMENT (Previously supported by this grant) AMENDMENT of items checked: 15 20 6. SOCIAL SECURITY NO. 7. BIRTHDATE (Month, day, year) 8. CITIZENSHIP (See instructions) 9. PERMANENT MAILING ADDRESS XXX-XX- U.S. Citizen or Noncitizen National Non-U.S. Citizen With a Permanent U.S. Resident Visa (“Green Card”) With a Temporary Not Residing in the U.S. If not a U.S. citizen, of which country are you a citizen? 10. Are you Hispanic (or Latino)? YES NO 11. What is your racial background? Check one or more E-mail Do Not Wish to Provide 12. Do you have a disability? American Indian or Alaska Native Native Hawaiian or other Pacific Islander YES Black or African American Do Not Wish to Provide Do Not Wish to Provide If yes, which of the following categories describe your disability(ies): Asian White NO Hearing Mobility/Orthopedic Impairment Visual Other 13. Are you from a disadvantaged background? (Applies to high school and undergraduate appointees only) Not Applicable YES NO Do Not Wish to Provide 15. PERIOD OF APPOINTMENT (Month, day, year) 14. FIELD OF RESEARCH TRAINING OR CAREER DEVELOPMENT (for this appointment) Enter a 3 digit code from instructions: From: To: 16. EDUCATION – AFTER HIGH SCHOOL (Indicate all academic and professional education. For foreign degrees, give U.S. equivalent.) (a) Name of Institution and Location (List most recent first) (b) Degree(s) Received Degree PHS 2271 (Rev. 03/17) Page 1 of 2 Mo./Yr. (c) Major Field (d) Minor Field 17. NAME OF SPECIALTY BOARDS (if applicable) 18. DEGREE(S) SOUGHT YES NO Are you in a dual degree program (e.g., M.D./Ph.D.)? If yes, indicate type of degree(s) YES NO 19. EXPECTED COMPLETION DATE FOR DEGREE(S) (mm/yyyy, if applicable) 20. SUPPORT FOR PERIOD OF APPOINTMENT TYPE Total for this Grant (Omit cents) Stipend / Salary / Other Compensation TOTAL $ $ 21. 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.) 22. CERTIFICATION AND ACCEPTANCE: I certify that the statements herein (a) SIGNATURE OF APPOINTEE 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 PROGRAM DIRECTOR 23. 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. (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 (b) DATE (b) DATE 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 Pain Medicine Pediatric Anesthesiology Sleep Medicine Colon and Rectal Surgery Colon and Rectal Surgery Dermatology Dermatology (General) Dermatopathology 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 Pediatric Emergency Medicine Sports Medicine Undersea and Hyperbaric Medicine Family Medicine Family Medicine (General) Adolescent Medicine Adult Congenital Heart Disease Geriatric Medicine Hospice and Palliative Medicine Sleep Medicine Sports Medicine Internal Medicine Internal Medicine (General) Adolescent Medicine Advanced Heart Failure and Transplant Cardiology Cardiovascular Disease Clinical Cardiac Electrophysiology Critical Care Medicine Endocrinology, Diabetes and Metabolism Gastroenterology Geriatric Medicine Hematology PHS 2271 (Rev. 06/15) — Attachment Hospice and Palliative Medicine Infectious Disease Interventional Cardiology Medical Oncology Nephrology Pulmonary Disease Rheumatology Sleep Medicine Sports Medicine Transplant Hepatology Medical Genetics Clinical Biochemical Genetics Clinical Cytogenetics Clinical Genetics (M.D.) Clinical Molecular Genetics Medical Biochemical Genetics Molecular Genetic Pathology Neurological Surgery Neurological Surgery Nuclear Medicine Nuclear Medicine Nursing Acute Care Nurse Practitioner Adult Nurse Practitioner Adult Psychiatric and Mental Health Nurse Practitioner Advanced Clinical Diabetes Management, Nurse Practitioner Gerontological Nurse Practitioner Clinical Nurse Specialist in Adult Psychiatric and Mental Health Nursing Clinical Nurse Specialist in Advanced Diabetes Nursing Clinical Nurse Specialist in Child and Adolescent Psychiatric and Mental Health Nursing Clinical Nurse Specialist in Gerontological Nursing Clinical Nurse Specialist in Home Health Nursing Clinical Nurse Specialist in Pediatric Nursing Clinical Nurse Specialist in Public/Community Health Nursing Family Nurse Practitioner Family Psychiatric and Mental Health Nurse Practitioner Pediatric Nurse Practitioner School Nurse Practitioner Obstetrics and Gynecology Obstetrics and Gynecology (General) Critical Care Medicine Female Pelvic Medicine and Reconstructive Surgery Gynecologic Oncology Hospice and Palliative Medicine Maternal and Fetal Medicine Reproductive Endocrinology/Infertility Ophthalmology Ophthalmology Orthopedic Surgery Orthopedic Surgery (General) Orthopedic Sports Medicine Surgery of the Hand Otolaryngology Otolaryngology (General) Neurotology 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 Neuropathology Pathology – Chemical Pathology – Forensic Pathology – Hematology 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 Neurodevelopmental Disabilities Pediatric Cardiology Pediatric Critical Care Medicine Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology-Oncology 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 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 PHS 2271 (Rev. 06/15) — Attachment Clinical Neurophysiology Epilepsy Forensic Psychiatry Geriatric Psychiatry Hospice and Palliative Medicine Neurodevelopmental Disabilities Neurology with Special Qualifications in Child Neurology Neuromuscular Medicine Pain Medicine Psychosomatic Medicine Sleep Medicine Vascular Neurology Radiology Diagnostic Radiology Hospice and Palliative Medicine Interventional Radiology and Diagnostic Radiology Medical Physics Neuroradiology Nuclear Radiology Pediatric Radiology Radiation Oncology Vascular and Interventional Radiology 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
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