Fillable Form Approved Through 02/28/2023 OMB No. 0925-0001: Ruth (National Institutes of Health)

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Form Approved Through 02/28/2023 OMB No. 0925-0001: Ruth (National Institutes of Health)

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PHS 6031 (Rev. 12/2020) Page 1
Form Approved Through 02/28/2023 OMB No. 0925-0001
Ruth L. Kirschstein National Research Service Award
Payback Agreement
To be completed by Trainees and Fellows before beginning the first 12 months of postdoctoral support.
COMPLETED FORM SHOULD BE MAILED TO THE AWARDING FEDERAL AGENCY GRANTS
MANAGEMENT OFFICE NAMED IN THE NOTICE OF AWARD.
THIS AGREEMENT IS A REQUIRED CONDITION OF
AWARD.
Introduction - Section 487 of the Public Health Service Act
contains service payback requirements for individuals
receiving Ruth L. Kirschstein National Research Service
Awards (NRSA). Under these requirements:
• Predoctoral Kirschstein-NRSA recipients will not incur
a payback obligation;
• Postdoctoral Kirschstein-NRSA recipients will incur a
payback obligation only during the initial 12 months of
postdoctoral Kirschstein-NRSA support;
• Postdoctoral Kirschstein-NRSA recipients in the 13th or
subsequent months of Kirschstein-NRSA support do
not incur any additional payback obligation.
Under these requirements, payback obligations stemming
from postdoctoral Kirschstein-NRSA support may be
discharged in the following ways:
• By receiving an equal period of postdoctoral
Kirschstein-NRSA support beginning in the 13th month
of such postdoctoral Kirschstein-NRSA support;
• By engaging in an equal period of health-related
research, health-related research training, health-
related teaching (or any combination thereof) that
averages at least 20 hours per week based on a full
work year.
Kirschstein−NRSA appointments or individual awards will
be governed by the service payback requirements
articulated in the National Research Service Award
Guidelines. These guidelines can be found in the NRSA
portion of the most recent version of the NIH Grants Policy
Statement found at:
http://grants.nih.gov/grants/policy/
policy.htm.
I. SERVICE REQUIREMENT
In accepting a Ruth L. Kirschstein National Research
Service Award to support my postdoctoral research
training, I understand that my first 12 months of Kirschstein-
NRSA support for postdoctoral research training carries
with it a payback obligation. I hereby agree to engage in a
month of health-related research, health-related research
training, or health-related teaching (or any combination
thereof) for each month I receive Kirschstein-NRSA support
for postdoctoral research training up to and including 12
months. If I receive Kirschstein-NRSA support for
postdoctoral research training for more than 12 months, I
agree that the 13th month and each subsequent month of
Kirschstein-NRSA-supported postdoctoral research
training will satisfy a month of my payback obligation
incurred in the first 12 months, excluding any period of time
in which the PHS has deferred my payback obligation (e.g.
during concurrent participation in the NIH Loan Repayment
Program). This payback service shall be initiated within 2
years after termination of Kirschstein-NRSA support,
unless the PHS extends (defers) the date in which I must
begin to undertake service, or the PHS waives my
obligation. If the date in which I must begin to undertake
service has been extended, I have an additional twelve
months to initiate service. The health-related research,
health-related research training, or health-related teaching
(or any combination thereof) undertaken for my service
obligation shall be on a continuous basis and shall average
at least 20 hours per week of a full work year. For
information regarding deferral of the NRSA payback
obligation due to concurrent participation in the NIH Loan
Repayment Program see: http://www.lrp.nih.gov
.
II. FINANCIAL PAYBACK PROVISIONS
I understand that if I fail to undertake or perform such
service in accordance with Section I, the United States will
be entitled to recover from me an amount determined in
accordance with the following formula:
A = F [(t-s)/t]
Where “A” is the amount the United States is entitled to
recover; “F” is the sum of the total amount paid to me under
the initial 12 months of my postdoctoral Ruth L. Kirschstein
National Research Service Award support; “t” is the total
number of months in my service obligation; and “s” is the
number of months of such obligation served.
Except as provided in Section III below, any amount the
United States is entitled to recover from me shall be paid
within the 3-year period beginning on the date the United
States becomes entitled to recover such amount. The
United States becomes entitled to recover such amount 2
years after termination of my Ruth L. Kirschstein National
Research Service Award support if I do not engage in
acceptable service payback activities in accordance with
Section I. If I elect to engage in financial repayment before
the end of the 2-year period, the United States becomes
PHS 6031 (Rev. 12/2020) Page 2
entitled to recover such amount on the date of my election.
Interest on the amount begins on the date the United States
becomes entitled to recover such amount and is at the rate
fixed by the Secretary of the Treasury after taking into
consideration private consumer rates prevailing on that
date. I understand that I will be allowed an initial 30-day
interest-free period in which to fully pay such amount, and
that I may prepay any outstanding balance after that period
to avoid additional interest. I further understand that I will
be subject to authorized debt collection action(s) (including
any accrued interest and late fees) should I fail to comply
with the payback provisions of this Section II.
III. CONDITIONS FOR BREAK IN SERVICE,
WAIVER, AND CANCELLATION
I hereby understand that the Secretary of Health and
Human Services:
A. May extend the period for undertaking service, permit
breaks in service, or extend the period for repayment, if
it is determine that:
1. Such an extension or break in service is
necessary to complete my clinical training or to
participate in a NIH Loan Repayment Program;
2. Completion would be impossible because of
temporary disability; or
3. Completion would involve a substantial hardship
and failure to extend such period would be against
equity and good conscience;
B. May waive my obligation, in whole or in part, if it is
determined that:
1. Fulfillment would be impossible because I am
permanently and totally disabled; or
2. Fulfillment would involve a substantial hardship
and the enforcement of such obligation would be
against equity and good conscience;
C. Will, in the event of my death, cancel any obligation
incurred under this payback agreement.
IV. TERMINATION NOTICE – ANNUAL REPORT
OF
EMPLOYMENT – CHANGE OF ADDRESS
AND
/OR NAME
I agree to complete and submit a Termination Notice (PHS
416-7) immediately upon completion of Kirschstein-NRSA
support. Thereafter, on an annual basis I agree to complete
and submit Annual Payback Activities Certification forms
sent to me by the awarding Federal Agency concerning
post-award activities, and agree to keep the awarding
Federal Agency advised of any change of address and/or
name until such time as my total obligation is fulfilled.
V. PROGRAM EVALUATION
I understand that I may also be contacted from time to time,
but no more frequently than once every 2 years, after the
termination of this award to determine how the training
obtained has influenced my career. Any information thus
obtained would be used only for statistical purposes and
would not identify me individually.
VI. CERTIFICATION
By signing the certification block below, I certify that I have
read and understood the requirements and provisions of
this assurance and that I will abide by them if an award is
made.
For additional questions regarding the Payback Agreement
contact:
NRSA Payback Service Center
Phone: (301) 594-1835 or (866) 298-9371
nrsapaybackcenter@mail.nih.gov
DO NOT RETURN THE COMPLETED FORM TO THIS
ADDRESS.
VII. MAILING
The completed form should be mailed to the awarding
Federal Agency Grants Management Office named in the
Notice of Award.
Public reporting burden for this collection of information is estimated to
average 5 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing sollection 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 (0925-0001). Do not return the completed form to this
address.
PHS 6031 (Rev. 12/2020) Page 3
Name (Last, first,
middle):
Nine Digit Social Security No. (Required):
- -
Signature:
Date:
Support received under the awarding
Federal agency Award/Grant Number:
Mailing Address:
E-mail:
Pr
ivacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the
Privacy Act: NIH 09-25-0225 https://era.nih.gov/privacy-act-and-era.htm
.
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Form Approved Through 02282023 OMB No. 0925-0001: Ruth (National Institutes of Health)

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Completed 1 February 2021

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