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

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.

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
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.

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
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:

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


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
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
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,

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)

ID Serial No.

3. SEX

2. APPOINTEE’S NAME (Last, first, initial)



Do Not Wish to Provide
4. TYPE OF ACTION (Check only one type)

5. PRIOR NRSA SUPPORT (Individual or institutional)

NEW appointment (NOT previously supported by this grant)

YES (If “Yes,” see instructions)

REAPPOINTMENT (Previously supported by this grant)
AMENDMENT of items checked:




7. BIRTHDATE (Month, day, year)

8. CITIZENSHIP (See instructions)



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)?



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


Do Not Wish to Provide
12. Do you have a disability?

American Indian or Alaska Native
Native Hawaiian or other Pacific Islander


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):





Mobility/Orthopedic Impairment



13. Are you from a disadvantaged background? (Applies to high school and
undergraduate appointees only)
Not Applicable



Do Not Wish to Provide

15. PERIOD OF APPOINTMENT (Month, day, year)

Enter a 3 digit code from instructions:



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)

PHS 2271 (Rev. 03/17)

Page 1 of 2


(c) Major Field

(d) Minor Field

17. NAME OF SPECIALTY BOARDS (if applicable)




Are you in a dual degree program (e.g., M.D./Ph.D.)?

If yes, indicate type
of degree(s)


19. EXPECTED COMPLETION DATE FOR DEGREE(S) (mm/yyyy, if applicable)

Total for this Grant (Omit cents)

Stipend / Salary / Other Compensation




21. STATEMENT OF NONDELINQUENCY ON U.S. FEDERAL DEBT. Is the appointee delinquent on the repayment of any U.S. Federal debt(s)?

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.
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.
(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 (General)
Critical Care Medicine
Hospice and Palliative Medicine
Pain Medicine
Pediatric Anesthesiology
Sleep Medicine
Colon and Rectal Surgery
Colon and Rectal Surgery
Dermatology (General)
Pediatric Dermatology
Dental Public Health
Oral and Maxillofacial Pathology
Oral and Maxillofacial Radiology
Oral and Maxillofacial Surgery
Orthodontics and Dentofacial
Pediatric Dentistry
Emergency Medicine
Emergency Medicine (General)
Anesthesiology Critical Care Medicine
Emergency Medical Services
Hospice and Palliative Medicine
Internal Medicine-Critical Care
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
Cardiovascular Disease
Clinical Cardiac Electrophysiology
Critical Care Medicine
Endocrinology, Diabetes and
Geriatric Medicine

PHS 2271 (Rev. 06/15) — Attachment

Hospice and Palliative Medicine
Infectious Disease
Interventional Cardiology
Medical Oncology
Pulmonary Disease
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
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
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
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

Orthopedic Surgery
Orthopedic Surgery (General)
Orthopedic Sports Medicine
Surgery of the Hand
Otolaryngology (General)
Pediatric Otolaryngology
Plastic Surgery Within the Head and
Sleep Medicine
Pathology - Anatomic/Pathology Clinical
Pathology - Anatomic
Pathology - Clinical
Blood Banking/Transfusion Medicine
Clinical Informatics
Pathology – Chemical
Pathology – Forensic
Pathology – Hematology
Pathology – Medical Microbiology
Pathology – Molecular Genetic
Pathology – Pediatric
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
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
Surgery of the Hand
Preventive Medicine
Aerospace Medicine
Clinical Informatics
Medical Toxicology
Occupational Medicine
Public Health and General Preventive
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
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
Diagnostic Radiology
Hospice and Palliative Medicine
Interventional Radiology and Diagnostic
Medical Physics
Nuclear Radiology
Pediatric Radiology

Radiation Oncology
Vascular and Interventional Radiology
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
Congenital Cardiac Surgery
Urology (General)
Female Pelvic Medicine and
Reconstructive Surgery
Pediatric Urology


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