Form Approved Through 06/30/2012 OMB No. 0925-0002
4. Description of a) health-related research/teaching activities; b) field of research/training duties; Department of Health and Human Services – Public Health Service and c) source of salary support. Include numbers of hours per week if not full time. Ruth L. Kirschstein National Research Service Award a. Annual Payback Activities Certification (APAC)
PLEASE TYPE. See instructions and Privacy Act information in transmittal letter. Please complete b. applicable sections. This form can also be downloaded from http://grants.nih.gov/grants/forms.htm#training. Retain a copy for your files. c.
Section I – Payback Status (Check applicable blocks[s]) Section III – Employment Information When Engaged in Payback 1. NAME OF SUPERVISOR NAME AND ADDRESS OF EMPLOYING Have not engaged in payback service during reporting period. (Complete Section IV.) ORGANIZATION 2. Have elected to engage in financial payback. (Complete Section IV.) 3. Request an extension of the 2-year period to initiate payback service or a break in TITLE service. Also check this box if you need an extension to participate in any of the NIH Loan Repayment Programs. (Specify need and length of extension under Section II, Item 4; complete Section IV.)
Have been engaged in continuous payback service during reporting period. (Complete 4. SIGNATURE OF SUPERVISOR OF RECORD Sections II, III, and IV.) DATE
If supervisor is retired or deceased or if you, the recipient, are self-employed, provide notarized Section II – Payback Service Description statement that reported employment information is accurate. 1. Number of months engaged in payback during this Section IV – Certification of Kirschstein-NRSA Recipient reporting period:
Dates: I certify that all of the above statements are true, complete, and correct to the best of my knowledge. (mm/dd/yyyy – mm/dd/yyyy) (A willfully false certification is a criminal offense. U.S. Code, Title 18, Section 1001). 2. Position Title : SIGNATURE
DATE 3. Payback Service SOCIAL SECURITY NO. DAYTIME TELEPHONE NO. E-MAIL
XXX-XX- a. Full-time position with biomedical or behavioral health-related research, health-related teaching, and/or health-related activities as primary activity. Section V – Acceptance by PHS Official (leave blank) b. Other position(s) where biomedical or behavioral health-related research, health-related NAME AND TITLE OF PHS OFFICIAL Extension date Number of months of teaching, and/or health-related activities averages at least 20 hours per week of a full payback service to acceptable service work year. begin or resume this reporting period
Section VI – Recipient Name and Address Update
NAME AND ADDRESS (Please correct if name and/or address has changed.)
PHS 6031-1 (Rev. 6/09)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
National Institutes of Health
Bethesda, MD 20892
To: Former Ruth L. Kirschstein National Research Service SPECIAL INSTRUCTIONS FOR APAC
Awardees 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 PAYBACK REQUIREMENTS 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 Under Section 487 of the Public Health Service (PHS) Act as amended (42 2 certifications,” etc. This form is available at: http://grants.nih.gov/grants/ USC 288), all individuals other than prebaccalaureate students who received a forms.htm #training. Ruth L. Kirschstein National Research Service Award (NRSA) prior to June 10,
1993, must engage in biomedical or behavioral health-related research and/or SECTION I health-related teaching for a period equal to the period of Kirschstein-NRSA
support in excess of 12 months.* 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 For Kirschstein-NRSA recipients who began appointments to training grants or payback or requesting an extension of the 2-year period in which to initiate activated fellowship awards on or after June 10, 1993, only the first twelve payback, sign and return the form; no further information is required. If the months of postdoctoral support will incur a service payback obligation. Such APAC covers the second year after termination of your Kirschstein-NRSA individuals may satisfy that obligation by engaging in an equal period of health-support, financial payback will be due 24 months after the termination date related research, health-related teaching, or health-related activities or by unless a request for an extension of the payback initiation period or a payback receiving an equal period of Kirschstein-NRSA supported postdoctoral research waiver is submitted and approved. training. Kirschstein-NRSA postdoctoral support beyond the initial 12 months
may also be used to satisfy a postdoctoral service obligation incurred for Item 2. Financial Payback: Those electing financial payback will be contacted awards which began before June 10, 1993. by the PHS with appropriate instructions.
By regulation (42 CFR Part 66), this service must be initiated within two years Item 3. Extension: Reasons for an extension or break in service include such after termination of Kirschstein-NRSA support. If payback service is not started things as physicians completing residency training, graduate students within the 2-year period, financial payback will become due unless an extension completing degree requirements, temporary disability or substantial hardship. of the period of undertaking payback or a waiver request has been approved by This item should also be used to report participation in any of the NIH Loan the PHS. Repayment Programs (LRP). Participation in LRP will result in a deferral of the
NRSA obligation because concurrent payback under both LRP and NRSA is ANNUAL PAYBACK ACTIVITIES CERTIFICATION, FORM PHS 6031-1 not permissible. If requesting an extension because of LRP participation,
include the start and end date of your LRP in Section II.4. The enclosed Annual Payback Activities Certification (APAC) form is the basic
communication between former Kirschstein-NRSA recipients and the PHS. Item 4. Engaged in Payback Service: This item includes regular payback Regardless of the nature of your present activities, complete and return the service (biomedical or behavioral health-related research, teaching, and/or form. Do not hesitate to provide supplemental information or request activities). For additional information on acceptable payback service, see the clarification of your obligation from the PHS agency that supported your training. Payback section of the most recent version of the NIH Grants Policy Statement
found at http://grants.nih.gov/grants/policy/policy.htm.
PHS 6031-1 (Rev. 6/09) Instructions
Record of Payback Obligation: The legislative allowance, when applicable, SECTION II
reflects the individual’s initial 12 months of support under the Kirschstein-NRSA Item 1. Number of Months: Indicate the number of months and dates funding authority which on appointments or fellowship awards started prior to (mm/dd/yyyy) engaged in payback service during this reporting period. Do not June 10, 1993, was not subject to payback.* Service credited is obtained from include any service already reported on previous APACs submitted. previous APAC reports.
Item 4. Description of Duties: The description of regular service should MAILING include sufficient information to serve as the basis for determination of
acceptability. It should include: (a) the specific activities (research, teaching, Return the completed APAC(s) with the necessary signatures, and one copy of health-related activities, etc.); (b) field of research/training duties; and (c) the any attachment(s), no later than 30 days after the reporting period end date to source(s) of salary supporting the activities. Include number of hours per week the address below. When the payback service or extension request is approved if not full time and the dates covered by each activity, if different from those in by PHS, a copy of the APAC will be returned to you. Section II, Item 1.
For any questions, please contact:
SECTION III NRSA Payback Service Center This section must be completed and signed by the supervisor(s) of record. Office of Extramural Programs
OER/OD/National Institutes of Health
SECTION IV 6011 Executive Boulevard, Suite 206, MSC 7650
Bethesda, MD 20892-7650 For those engaged in payback service, the APAC should be signed on or after Phone: (301) 594-1835 or (866) 298-9371 the end date reported in Section II, Item 1. The PHS requests the last four digits
of the Social Security Number in order to maintain accurate payback records for NIH estimates that it will take 20 minutes to complete this form. This includes former Kirschstein-NRSA trainees and fellows and is authorized to collect this time for reviewing the instructions, gathering needed information, and information under Section 487 of the Public Health Service Act. Providing your completing and reviewing the form. An agency may not conduct or sponsor, Social Security Number is voluntary and you will not be deprived of any Federal and a person is not required to respond to, a collection of information unless it rights, benefits or privileges for refusing to disclose it. displays a currently valid OMB control number. If you have comments regarding
this burden estimate or any other aspect of this collection of information, PREPRINTED INFORMATION including suggestions for reducing this burden, send comments to NIH Project
Clearance Office, 6705 Rockledge Drive MSC 7974, Bethesda, MD 20892-Address Verification: Until your payback obligation is completed, report 7974, ATTN: PRA (0925-0002). DO NOT RETURN THE COMPLETED FORM immediately any change in name or address to the Kirschstein-NRSA Payback TO THIS ADDRESS. Service Center.
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. * Individuals in delinquent payback status prior to August 13, 1981, have a payback
obligation for the total amount of time of Kirschstein-NRSA support.
PHS 6031-1 (Rev. 6/09) Instructions
Privacy Act Statement
The Public Health Service requests this information pursuant to statutory authorities a. the DHHS, or any component thereof;
contained in Section 405(a) and 487 of the Public Health Service Act, as amended (42 b. any DHHS employee in his or her official capacity; USC 284(b)(1)C and 288), and other statutory authorities (42 USC 242(a), 280(b)(4),
and 29 USC 670). The information collected will facilitate postaward management and c. any DHHS employee in his or her individual capacity where the Department of evaluation of PHS programs. The social security number is requested to provide a Justice (or the DHHS, where it is authorized to do so) has agreed to represent the reliable identifier that will assist in establishing an accurate and complete record for each employee; or individual. It is particularly useful in maintaining effective communication with those d. the United States or any agency thereof, where the DHHS determines that the individuals who have incurred payback obligations through their participation in the Ruth litigation is likely to affect the DHHS or any of its components. L. Kirschstein National Research Service Award program. Failure to provide the social
security number may seriously diminish PHS’s capability to credit the account of the 8. A record may also be disclosed for a research purpose, when the DHHS: proper trainee who is fulfilling the payback requirement by either acceptable service a. has determined that the use or disclosure does not violate legal or policy and/or monetary repayment. limitations under which the record was provided, collected, or obtained; The PHS maintains application and grant records as part of a system of records as
defined by the Privacy Act: 09-25-0036, “Extramural Awards and Chartered Advisory b. has determined that the research purpose (1) cannot be reasonably Committees.” The Privacy Act of 1974 (5 USC 552a) allows disclosures for “routine accomplished unless the record is provided in individually identifiable form, and (2) uses” and permissible disclosures. warrants the risk to privacy of the individual that additional exposure of the record
might bring; Some routine uses may be:
c. has secured a written statement attesting to the recipient’s understanding of, and 1. To the cognizant audit agency for auditing. willingness to abide by, these provisions; and 2. To a Congressional office from a record of an individual in response to an inquiry d. has required the recipient to: from the Congressional office made at the request of that individual.
(1) establish reasonable administrative, technical, and physical safeguards to 3. To qualified experts, not within the definition of DHHS employees as prescribed in prevent unauthorized use or disclosure of the record; DHHS regulations (45 CFR 5b.2) for opinions as part of the application review
process. (2) remove or destroy the information that identifies the individual at the earliest
time at which removal or destruction can be accomplished consistent with the 4. To a Federal agency, in response to its request, in connection with the letting of a purpose of the research project, unless the recipient has presented adequate contract or the issuance of a license, grant, or other benefit by the requesting agency, justification of a research or health nature for retaining such information; and to the extent that the record is relevant and necessary to the requesting agency’s
decision on the matter. (3) make no further use or disclosure of the record, except (a) in emergency
circumstances affecting the health or safety of any individual, (b) for use in 5. To organizations in the private sector with whom PHS has contracted for the purpose another research project, under these same conditions, and with written of collating, analyzing, aggregating, or otherwise refining records in a system. authorization of the DHHS, (c) for disclosure to a properly identified person for the Relevant records will be disclosed to such a contractor, who will be required to purpose of an audit related to the research project, if information that would maintain Privacy Act safeguards with respect to such records. enable research subjects to be identified is removed or destroyed at the earliest 6. To the sponsoring organization in connection with the review of an application or opportunity consistent with the purpose of the audit, or (d) when required by law. performance or administration under the terms and conditions of the award, or in The Privacy Act also authorizes discretionary disclosures where determined appropriate connection with problems that might arise in performance or administration if an by the PHS, including to law enforcement agencies, to the Congress acting within its award is made. legislative authority, to the Bureau of the Census, to the National Archives, to the 7. To the Department of Justice, to a court or other tribunal, or to another party before General Accounting Office, pursuant to a court order, or as required to be disclosed by such tribunal, when one of the following is a party to litigation or has any interest in the Freedom of Information Act of 1974 (5 USC 552) and the associated DHHS such litigation, and the DHHS determines that the use of such records by the regulations (45 CFR Part 5). Department of Justice, the tribunal, or the other party is relevant and necessary to
the litigation and would help in the effective representation of the governmental party.
PHS 6031-1 (Rev. 6/09) Privacy Act