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Phs 2271 (rev. 06/09), Statement Of Training Appointment

Instructions for PHS 2271
Form Approved Through 06/30/2012
Revised 06/09
OMB No. 0925-0001
U.S. Department of Health and Human Services
Public Health Service
Information and Instructions for Completing
Statement of Appointment (Form PHS 2271)
The Public Health Service (PHS) estimates that it will take 15 minutes to complete this form. This
includes time for reviewing the instructions, gathering needed information, and completing and
reviewing the form. 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. If you have
comments regarding the amount of time it takes to complete this form or any other aspects of this
collection of information, including suggestions for reducing this burden, send comments to: NIH,
Project Clearance Office, 6705 Rockledge Drive MSC 7974, Bethesda, MD 20592-7974, ATTN: PRA
(0925-0001). 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 non-
NRSA institutional research training programs (e.g., T15). 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 generally do
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. 06/09) — 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 non-
NRSA 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. Include maiden name or other names in parentheses
where applicable.
Item 3. Sex. Self-explanatory.
Item 4. Type of Action.
New Appointment: When an individual has not been previously supported by this training 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 2 (Name); 9 (Permanent Mailing
Address); 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.
PHS 2271 (Rev. 06/09) — Instructions
Item 5. Prior NRSA Support. Individuals being appointed to a Kirschstein-NRSA institutional grant
for the first time or being reappointed after a break in support must indicate if they have received prior
Kirschstein-NRSA support from either an individual award or institutional grant. If yes, specify on the
form the dates of support, the level (pre- or post-), the mechanism (individual award or institutional
grant), and the grant number, if known. (See the Program Guidelines for limitations on total period of
support.)
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, non-
citizen 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) for citizenship
requirements.
Item 9. Permanent Mailing Address. Give an address where the appointed individual can be
reached by mail after completion of the program. (Do not give present address unless it is 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”.
PHS 2271 (Rev. 06/09) — Instructions
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.
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.
13. Are you from a disadvantaged background?
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,
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. Individuals falling in this category must have qualified for Federal disadvantaged
assistance or have received Health Professional Student Loans (HPSL), Loans for
Disadvantaged Student Program, or scholarships from the U.S. Department of Health and
Human Services under the Scholarship for Individuals with Exceptional Financial Need.
2. Comes from a social, cultural, or 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. This category is most applicable to high school and perhaps undergraduate
students, but more difficult to justify for individuals beyond that level of achievement.
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. Use the subcode (nonbold
lowercase) unless the broader category (bold uppercase) fits best.
PHS 2271 (Rev. 06/09) — Instructions
3940 Health
Education
1000 I. Predominantly Non-Clinical
2400 MICROBIOLOGY
AND
3950 Health Policy Research
or Lab-Based Research
INFECTIOUS DISEASES
3960 Health Services Research
Training
2410 Bacteriology
3970 Occupational and Environmental
2420 Etiology
1100 BIOCHEMISTRY
Health
2430 HIV/AIDS
1110 Biological
Chemistry
2440 Mycology
4100 RADIATION,
NON-CLINICAL
1120 Bioenergetics
2450 Parasitology
4110 Nuclear
Chemistry
1130 Enzymology
2460 Pathogenesis of Infectious
4120 Radiation
Physics
1140 Metabolism
Diseases
4130 Radiobiology
1200 BIOENGINEERING
2470 Virology
4200 SOCIAL
SCIENCES
1210 Bioelectric/Biomagnetic
2600 MOLECULAR
BIOLOGY
4210 Anthropology
1220 Biomaterials
4220 Bioethics
1230 Biomechanical
Engineering
2800 NEUROSCIENCE
4230 Demography & Population
1240 Imaging
2810 Behavioral
Neuroscience
Studies
1250 Instrumentation
and
Devices
2820 Cellular
neuroscience
4240 Economics
1260 Mathematical
Modeling
2830 Cognitive
neuroscience
4250 Education
1270 Medical Implant Science
2840 Communication
Neuroscience
4260 Language and Linguistics
1280 Nanotechnology
2850 Computational
Neuroscience
4270 Sociology
1290 Rehabilitation
Engineering
2860 Developmental
Neuroscience
1310 Tissue
Engineering
2870 Molecular
Neuroscience
4400 STATISTICS
AND/OR
2880 Neurochemistry
RESEARCH METHODS AND/OR
1400 BIOPHYSICS
2890 Neurodegeneration
INFORMATICS
1410 Kinetics
2910 Neuropharmacology
4410 Biostatistics and/or Biometry
1420 Spectroscopy
2920 Systems/Integrative
4420 Bioinformatics
1430 Structural
Biology
Neuroscience
4430 Computational
Science
1440 Theoretical
Biophysics
4440 Information
Science
3100 NUTRITIONAL
SCIENCES
1500 BIOTECHNOLOGY
4450 Clinical Trials Methodology
1510 Applied Molecular Biology
3200 PHARMACOLOGY
4600
TRAUMA,
NON
CLINICAL
1520 Bioprocessing and Fermentation
3210 Molecular
Pharmacology
1530 Metabolic
Engineering
3220 Pharmacodynamics
5000 OTHER,
Predominantly
Non-
3230 Pharmacogenetics
Clinical or Lab-Based Research
1600 CELL
AND
DEVELOPMENTAL
3240 Toxicology
Training
BIOLOGY
1610 Cell
Biology
3300 PHYSIOLOGY
6000 II. Predominantly Clinical
1620 Developmental
Biology
3310 Aging
Research Training (can
3320 Anesthesiology
(basic
science)
include any degree)
1700 CHEMISTRY
3330 Endocrinology
(basic science)
1710 Analytical
Chemistry
3340 Exercise Physiology (basic
6100 ALLIED
HEALTH
1720 Bioinorganic
Chemistry
science)
6110 Audiology
1730 Bioorganic
Chemistry
3350 Integrative
Biology
6120 Community
Psychology
1740 Biophysical
Chemistry
3360 Molecular
Medicine
6130 Exercise Physiology (clinical)
1750 Medicinal
Chemistry
3370 Physiological
Optics
6140 Medical
Genetics
1760 Physical
Chemistry
3380 Reproductive
Physiology
6150 Occupational
Health
1770 Synthetic
Chemistry
6160 Palliative
Care
3500 PLANT
BIOLOGY
6170 Physical
Therapy
1900
ENVIRONMENTAL
SCIENCES
6180 Pharmacy
3600 PSYCHOLOGY,
NON-CLINICAL
2000 GENETICS
6190 Social
Work
3610 Behavioral
Communication
2010 Behavioral
Genetics
6210 Speech-language
Pathology
Sciences
2020 Developmental
Genetics
6211 Rehabilitation
3620 Behavioral Medicine (non-clinical)
2030 Genetic
Epidemiology
3630 Cognitive
Psychology
6400 DENTISTRY
2040 Genetics of Aging
3640 Developmental and Child
2050 Genomics
Psychology
6500 CLINICAL
DISCIPLINES
2060 Human
Genetics
3650 Experimental
&
General
6510 Allergy
2070 Molecular
Genetics
Psychology
6520 Anesthesiology
2080 Population
Genetics
3660 Mind-Body
Studies
6530 Behavioral Medicine (clinical)
6540 Cardiovascular
Diseases
2200 IMMUNOLOGY
3680 Neuropsychology
6550 Clinical Laboratory Medicine
2210 Asthma and Allergic Mechanisms
3690 Personality
and
Emotion
6560 Clinical
Nutrition
2220 Autoimmunity
3710 Physiological Psychology &
6570 Clinical
Pharmacology
2230 Immunodeficiency
Psychobiology
6580 Complementary
and
Alternative
2240 Immunogenetics
3720 Psychology of Aging
Medicine
2250 Immunopathology
3730 Psychometrics
6590 Clinical
Psychology
2260 Immunoregulation
3740 Psychophysics
6610 Connective Tissue Diseases
2270 Inflammation
3750 Social
Psychology
6620 Dermatology
2280 Structural
Immunology
3900 PUBLIC
HEALTH
6630 Diabetes
2290 Transplantation
Biology
3910 Disease Prevention and Control
6640 Gastroenterology
2310 Vaccine
Development
3920 Epidemiology
6650 Endocrinology
3930 Health
Economics
6660 Immunology
PHS 2271 (Rev. 06/09) — Instructions
6670 Gene Therapy (clinical)
6910 Oncology
7300 PEDIATRIC
DISCIPLINES
6680 Geriatrics
6920 Orthopedics
7310 Pediatric
Endocrinology
6690 Hematology
6930 Otorhinolarynology
7320 Pediatric
Hematology
6710 HIV/AIDS
6940 Preventive
Medicine
7330 Pediatric
Oncology
6820 Infectious
Diseases
6950 Radiation,
Interventional
7340 Pediatric, Prematurity & Newborn
6830 Liver
Diseases
6960 Pulmonary
Diseases
6840 Metabolic
Diseases
6970 Radiology,
Diagnostic
7500 NURSING
6850 Nephrology
6980 Rehabilitation
Medicine
7700 VETERINARY
MEDICINE
6860 Neurology
6990 Psychiatry
6870 Ophthalmology
7110 Surgery
8000 OTHER,
Predominantly
Clinical
6880 Nuclear
Medicine
7120 Trauma
Research Training
6890 OB-GYN
7130 Urology
Item 15. Period of this Appointment. The period shown in most cases will be 12 months.
Appointment periods may exceed 12 months in rare cases and only with prior approval from the PHS.
The amount of the stipend/salary and tuition for each full period of appointment must be obligated
from funds available at the time the appointment begins, unless other arrangements have been made
with PHS.
Other instructions should be requested where institutional accounting practice precludes obligations of
stipend/salary and tuition in the amount required for the full appointment period.
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. Indicate whether the
appointee is in a dual degree program (e.g., M.D./Ph.D.).
Include the date that all degree requirements are expected to be completed.
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 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, on the line for
stipend/salary/other compensation.
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.
PHS 2271 (Rev. 06/09) — Instructions
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.
• For grants, organizations in receipt of a “Notice of Grants Cost Disallowance” which have not repaid
the disallowed amount or which have not resolved the disallowance. (This definition excludes
disallowance in an “appeal” status.)
Item 22. Certification and Signature of Appointee. Self-explanatory.
Item 23. Certification, Signature, and Address of Program Director. Self-explanatory.
PHS 2271 (Rev. 06/09) — Instructions
Form Approved Through 06/30/2012
OMB No. 0925-0001
Department of Health and Human Services
Follow attached instructions carefully. Submit this form at the time the
Public Health Services
individual is appointed, is reappointed, or the reported appointment is amended.
Statement of Appointment
Return this form to the PHS awarding component. For new postdoctoral trainees
under NRSA, signed and dated payback agreement must accompany this form.
(Please Type)
1. PHS GRANT NUMBER
2. APPOINTEE’S NAME (Last, first, initial)
3. SEX
Type
Activity
ID Serial No.
M
F
4. TYPE OF
ACTION
(Check only one type)
5. PRIOR NRSA
SUPPORT
(Individual or institutional)
NEW appointment (NOT previously supported by this grant)
NO
YES (If “Yes,” see instructions)
REAPPOINTMENT (Previously supported by this grant)
AMENDMENT of items checked:
2
9
15
20
6. SOCIAL
SECURITY
NO.
7. BIRTHDATE
(Month, day, year)
XXX-XX-
8. CITIZENSHIP
(See instructions)
9. PERMANENT MAILING ADDRESS
U.S. Citizen or Noncitizen National
Non-U.S. Citizen
With a Permanent U.S. Resident Visa (“Green Card”)
With a Temporary U.S. Visa
If not a U.S. citizen, of which country are you a citizen?
E-mail
10. Are you Hispanic (or Latino)?
YES
NO
Do Not Wish to Provide
11. What is your racial background? Check one or more
12. Do you have a disability?
American Indian or Alaska Native
YES
NO
Do Not Wish to Provide
Native Hawaiian or other Pacific Islander
If yes, which of the following categories describe your disability(ies):
Asian
Hearing
Mobility/Orthopedic Impairment
Black or African American
Visual
Other
White
13. Are you from a disadvantaged background?
Do Not Wish to Provide
YES
NO
Do Not Wish to Provide
14. FIELD OF RESEARCH TRAINING OR CAREER DEVELOPMENT (for this 15. PERIOD OF APPOINTMENT (Month, day, year)
appointment)
Enter a 4 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
(b) Degree(s)
(c) Major Field
(d) Minor Field
(List most recent first)
Received
Degree
Mo./Yr.
PHS 2271 (Rev. 06/09)
Page 1 of 2
17. NAME OF SPECIALTY BOARDS (if applicable)
If yes, indicate type
18. DEGREE(S) SOUGHT
YES
NO
of degree
Are you in a dual degree program (e.g., M.D./Ph.D.)?
YES
NO
19. EXPECTED COMPLETION DATE OF DEGREE REQUIREMENTS (if applicable)
20. SUPPORT FOR PERIOD OF APPOINTMENT
TYPE
Total for this Grant (Omit cents)
Stipend / Salary / Other Compensation
$
Tuition/fees (estimated)
$
Travel (estimated)
$
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
(b) DATE
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 (b) DATE
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) TYPED NAME OF PROGRAM DIRECTOR
(d) INSTITUTION’S NAME, ADDRESS, AND PHONE NO.
(Street, city, state, zip code)
PHS 2271 (Rev. 06/09)
Page 2 of 2
Privacy Act Statement
The PHS maintains application and grant records as part of a system of records as defined by the Privacy Act: 09-25-
0112, Grants and Cooperative Agreements: Research, Research Training, Fellowship, and Construction Applications
and Related Awards. The Privacy Act of 1974 (5 USC 522a) allows disclosures for “routine uses” and permissible
disclosures.
Some routine uses may be:
1. To the cognizant audit agency for auditing.
2. To a Congressional office from a record of an individual in response to an inquiry from the Congressional office
made at the request of that individual.
3. To qualified experts, not within the definition of DHHS employees as prescribed in DHHS regulations (45 CFR 5b.2)
for opinions as part of the application review process.
4. To a Federal agency, in response to its request, in connection with the letting of a contract or the issuance of a
license, grant, or other benefit by the requesting agency, to the extent that the record is relevant and necessary to
the requesting agency’s decision on the matter;
5. To organizations in the private sector with whom PHS has contracted for the purpose of collating, analyzing,
aggregating, or otherwise refining records in a system. Relevant records will be disclosed to such a contractor, who
will be required to maintain Privacy Act safeguards with respect to such records.
6. To the sponsoring organization in connection with the review of an application or performance or administration
under the terms and conditions of the award, or in connection with problems that might arise in performance or
administration if an award is made.
7. To the Department of Justice, to a court or other tribunal, or to another party before such tribunal, when one of the
following is a party to litigation or has any interest in such litigation, and the DHHS determines that the use of such
records by the 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.
a. the DHHS, or any component thereof;
b. any DHHS employee in his or her official capacity;
c.
any DHHS employee in his or her individual capacity where the Department of Justice (or the DHHS, where it
is authorized to do so) has agreed to represent the employee; or
d. the United States or any agency thereof; where the DHHS determines that the litigation is likely to affect the
DHHS or any of its components.
8. A record may also be disclosed for a research purpose, when the DHHS:
a. has determined that the use or disclosure does not violate legal or policy limitations under which the record
was provided, collected, or obtained;
b. has determined that the research purpose (1) cannot be reasonably accomplished unless the record is
provided in individually identifiable form, and (2) warrants the risk to the privacy of the individual that additional
exposure of the record might bring;
c.
has secured a written statement attesting to the recipient’s understanding of; and willingness to abide by,
these provisions; and
d. has required the recipient to:
(1) establish reasonable administrative, technical, and physical safeguards to prevent unauthorized use or
disclosure of the record;
(2) destroy the information that identifies the individual at the earliest time at which removal or destruction can
be accomplished consistent with the purpose of the research project, unless the recipient has presented
adequate justification of a research or health nature for retaining such information; and
(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 another research project, under these same conditions, and with
written authorization of the DHHS, (c) for disclosure to a properly identified person for the purpose of an
audit related to the research project, if information that would enable research subjects to be identified is
removed or destroyed at the earliest opportunity consistent with the purpose of the audit, or (d) when
required by law.
The Privacy Act also authorizes discretionary disclosures where determined appropriate by the PHS, including to law
enforcement agencies, to the Congress acting within its legislative authority, to the Bureau of the Census, to the
National Archives, to the General Accounting Office, pursuant to a court order, or as required to be disclosed by the
Freedom of Information Act of 1974(5 USC 552) and the associated DHHS regulations (45 CFR Part 5).
PHS 2271 (Rev. 06/09) — Privacy Act
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.
Sleep Medicine
Surgery of the Hand
Allergy and Immunology
Sports Medicine
Allergy and Immunology
Transplant Hepatology
Otolaryngology
Otolaryngology (General)
Anesthesiology
Medical Genetics
Neurotology
Anesthesiology (General)
Clinical Biochemical Genetics
Pediatric Otolaryngology
Critical Care Medicine
Clinical Cytogenetics
Plastic Surgery Within the Head and
Hospice and Palliative Medicine
Clinical Genetics (M.D.)
Neck
Pain Medicine
Clinical Molecular Genetics
Sleep Medicine
Colon and Rectal Surgery
Molecular Genetic Pathology
Pathology
Colon and Rectal Surgery
Ph.D. Medical Genetics
Anatomic Pathology and Clinical
Dermatology
Neurological Surgery
Pathology (General)
Dermatology (General)
Neurological Surgery
Pathology-Anatomic (General)
Clinical and Laboratory Dermatological
Pathology-Clinical (General)
Nuclear Medicine
Dermatopathology
Blood Banking/Transfusion Medicine
Nuclear Medicine
Immunology
Chemical Pathology
Pediatric Dermatology
Nursing
Cytopathology
Acute Care Nurse Practitioner
Dermatopathology
Dental
Adult Nurse Practitioner
Forensic Pathology
Dental Public Health
Adult Psychiatric and Mental Health
Hematology
Endodontics
Nurse Practitioner
Medical Microbiology
Oral and Maxillofacial Pathology
Advanced Clinical Diabetes
Molecular Genetic Pathology
Oral and Maxillofacial Radiology
Management, Clinical Nurse
Neuropathology
Oral and Maxillofacial Surgery
Specialist
Pediatric Pathology
Orthodontics and Dentofacial
Advanced Clinical Diabetes
Orthopedics
Pediatrics
Management, Nurse Practitioner
Pediatric Dentistry
Pediatrics (General)
Gerontological Nurse Practitioner
Periodontics
Adolescent Medicine
Clinical Nurse Specialist in Adult Health
Prosthodontics
Child Abuse Pediatrics
(formerly Medical-Surgical) Nursing
Developmental-Behavioral Pediatrics
Emergency Medicine
Clinical Nurse Specialist in Adult
Hospice and Palliative Medicine
Emergency Medicine (General)
Psychiatric and Mental Health
Medical Toxicology
Hospice and Palliative Medicine
Nursing
Neonatal-Perinatal Medicine
Medical Toxicology
Clinical Nurse Specialist in Child and
Neurodevelopmental Disabilities
Pediatric Emergency Medicine
Adolescent Psychiatric and Mental
Pediatric Cardiology
Sports Medicine
Health Nursing
Pediatric Critical Care Medicine
Undersea and Hyperbaric Medicine
Clinical Nurse Specialist in Home
Pediatric Emergency Medicine
Health Nursing
Pediatric Endocrinology
Family Medicine
Clinical Nurse Specialist in Pediatric
Pediatric Gastroenterology
Family Medicine (General)
Nursing
Pediatric Hematology-Oncology
Adolescent Medicine
Clinical Nurse Specialist in
Pediatric Infectious Diseases
Geriatric Medicine
Public/Community Health Nursing
Pediatric Nephrology
Hospice and Palliative Medicine
Clinical Nurse Specialist in
Pediatric Pulmonology
Sleep Medicine
Gerontological Nursing
Pediatric Rheumatology
Sports Medicine
Family Nurse Practitioner
Pediatric Transplant Hepatology
Family Psychiatric and Mental Health
Internal Medicine
Sleep Medicine
Nurse Practitioner
Internal Medicine (General)
Sports Medicine
Pediatric Nurse Practitioner
Adolescent Medicine
School Nurse Practitioner
Physical Medicine and Rehabilitation
Cardiovascular Disease
Physical Medicine and Rehabilitation
Clinical Cardiac Electrophysiology
Obstetrics and Gynecology
(General)
Critical Care Medicine
Obstetrics and Gynecology (General)
Hospice and Palliative Medicine
Endocrinology, Diabetes and
Critical Care Medicine
Pain Medicine
Metabolism
Gynecologic Oncology
Neuromuscular Medicine
Gastroenterology
Hospice and Palliative Medicine
Pediatric Rehabilitation Medicine
Geriatric Medicine
Maternal and Fetal Medicine
Spinal Cord Injury Medicine
Hematology
Reproductive Endocrinology/Infertility
Sports Medicine
Hospice and Palliative Medicine
Infectious Disease
Ophthalmology
Plastic Surgery
Interventional Cardiology
Ophthalmology
Plastic Surgery (General)
Medical Oncology
Orthopaedic Surgery
Plastic Surgery Within the Head and
Nephrology
Orthopaedic Surgery (General)
Neck
Pulmonary Disease
Orthopaedic Sports Medicine
Surgery of the Hand
Rheumatology
PHS 2271 (Rev. 06/09) — Attachment
Preventive Medicine
Neurodevelopmental Disabilities
Vascular and Interventional Radiology
Aerospace Medicine
Neurology with Special Qualifications in
Medical Toxicology
Child Neurology
Surgery
Occupational Medicine
Neuromuscular Medicine
Surgery (General)
Public Health and General Preventive
Pain Medicine
Hospice and Palliative Medicine
Medicine
Psychosomatic Medicine
Pediatric Surgery
Undersea and Hyperbaric Medicine
Sleep Medicine
Surgery of the Hand
Vascular Neurology
Surgical Critical Care
Psychiatry and Neurology
Vascular Surgery
Neurology (General)
Radiology
Psychiatry (General)
Diagnostic Radiology
Thoracic Surgery
Addiction Psychiatry
Hospice and Palliative Medicine
Thoracic Surgery
Child and Adolescent Psychiatry
Neuroradiology
Urology
Clinical Neurophysiology
Nuclear Radiology
Urology (General)
Forensic Psychiatry
Pediatric Radiology
Pediatric Urology
Geriatric Psychiatry
Radiation Oncology
Hospice and Palliative Medicine
Radiologic Physics
PHS 2271 (Rev. 06/09) — Attachment