Form Approved Through 10/31/2018 OMB No. 0925-0001
Department of Health and Human Services
Public Health Service
Ruth L. Kirschstein National Research Service Award
Individual Fellowship Activation Notice
FELLOWSHIP NUMBER:
DATE FELLOW ENTERED ON DUTY (Month, day, year):
1. All fellows must complete this form for the first year of their fellowship, indicating their start date under the fellowship
and other requested information.
2. Send the signed original of the completed form to the awarding agency using the address provided in the Notice of
Award. This should be submitted immediately after the fellow enters on duty. Keep a copy; one will not be returned. This
form must be completed online, printed, and then signed for submission to PHS.
3. An appropriate statement regarding degrees (certified by degree-granting institution) MUST be attached if such
contingency appears on the award notice.
4. For Ruth L. Kirschstein National Research Service Award fellows in their first 12 months of postdoctoral support, a
signed payback agreement MUST accompany this form.
5. No funds may be disbursed until the fellow enters on duty and the proper forms are submitted to PHS.
6. As a condition of this activation, all NRSA fellows agree to complete and submit a Termination Notice (PHS 416-7)
immediately upon completion of support.
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 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 (0925-0001). Do not return the completed form to this address.
RETURN TO: The awarding agency, using the contact information provided on the Notice of Award. Contact the assigned
Grants Management Specialist for questions.
NAME OF FELLOW (Last, first, middle):
HIGHEST DEGREE(S):
NAME OF SPONSORING INSTITUTION:
REQUIRED SIGNATURES E-MAIL PHONE NO. DATE
FELLOW
SPONSOR
INSTITUTIONAL BUSINESS OFFICIAL
DO NOT WRITE IN THIS BLOCK (For PHS use only)
AWARD PERIOD:
From:
Through:
PROCESSED BY/DATE:
NOTES:
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.
PHS 416-5 (Rev. 6/15)
