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Phs-6031-1 FORM PHS 6031-1

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Form Approved Through 03/31/2020 OMB No. 0925-0002
Department of Health and Human Services – Public Health Service
Ruth L. Kirschstein National Research Service Award
Annual Payback Activities Certification (APAC)
See instructions and Privacy Act information in transmittal letter. Please complete applicable
sections. This form can also be downloaded from http://grants.nih.gov/grants/forms.htm#training.
Retain a copy for your files.
Section I – Payback Status (Check applicable blocks[s])
1.
Have not engaged in payback service during reporting period. (Complete Section IV.)
2.
Have elected to engage in financial payback. (Complete Section IV.)
3.
Request a 12 month extension period to initiate payback service or a break in service.
Also check this box if you need an extension to participate in any of the NIH Loan
Repayment Programs. Specify the need for the extension under Section II, Item 4.
(Complete Section IV.)
4.
Have been engaged in continuous payback service during reporting period.
(Complete Sections II, III, and IV.)
Section II – Payback Service Description
1. Number of months engaged in payback during this
reporting period:
Dates: (mm/dd/yyyy – mm/dd/yyyy)
2. Position Title:
3. Payback Service
a.
Full-time position with biomedical or behavioral health-related research, health-related
teaching, and/or health-related activities as primary activity.
b.
Other position(s) where biomedical or behavioral health-related research, health-related
teaching, and/or health-related activities averages at least 20 hours per week of a full
work year.
4. Description of a) health-related research/teaching activities; b) field of research/training
duties; and c) source of salary support. Include numbers of hours per week if not full time.
a.
b.
c.
Section III – Employment Information When Engaged in Payback
NAME AND ADDRESS OF EMPLOYING
ORGANIZATION
NAME OF PAYBACK SERVICE SUPERVISOR
TITLE
SIGNATURE OF PAYBACK SERVICE SUPERVISOR
DATE
I certify that all of the above statements are true, complete, and correct to the best of my
knowledge. (A willfully false certification is a criminal offense. U.S. Code, Title 18, Section 1001.)
If supervisor is retired or deceased or if you, the recipient, are self-employed, provide notarized
statement that reported employment information is accurate.
Section IV – Recipient Name and Address
NAME AND ADDRESS
Section V – Certification of Kirschstein-NRSA Recipient
I certify that all of the above statements are true, complete, and correct to the best of my
knowledge. (A willfully false certification is a criminal offense. U.S. Code, Title 18, Section 1001).
SIGNATURE
DATE
SOCIAL SECURITY NO.
XXX-XX-
DAYTIME TELEPHONE NO. E-MAIL
Section VI – Acceptance by PHS Official (leave blank)
NAME AND TITLE OF PHS OFFICIAL
Extension date
payback service to
begin or resume
Number of months of
acceptable service
this reporting period
SIGNATURE
DATE
PHS 6031-1 (Rev. 06/15)
Page 1 of 3
PSC Publishing Services (301) 443-6740
EF
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
National Institutes of Health
Bethesda, MD 20892
To: Former Ruth L. Kirschstein National Research Service
Awardees
PAYBACK REQUIREMENTS
Under Section 487 of the Public Health Service (PHS) Act as amended (42
USC 288), all individuals other than prebaccalaureate students who received a
Ruth L. Kirschstein National Research Service Award (NRSA) prior to June 10,
1993, must engage in biomedical or behavioral health-related research and/or
health-related teaching for a period equal to the period of Kirschstein-NRSA
support in excess of 12 months.*
For Kirschstein-NRSA recipients who began appointments to training grants or
activated fellowship awards on or after June 10, 1993, only the first twelve
months of postdoctoral support will incur a service payback obligation. Such
individuals may satisfy that obligation by engaging in an equal period of health-
related research, health-related teaching, or health-related activities or by
receiving an equal period of Kirschstein-NRSA supported postdoctoral
research training. Kirschstein-NRSA postdoctoral support beyond the initial 12
months may also be used to satisfy a postdoctoral service obligation incurred
for awards which began before June 10, 1993.
By regulation (42 CFR Part 66), this service must be initiated within two years
after termination of Kirschstein-NRSA support. If payback service is not started
within the 2-year period, financial payback will become due unless an extension
of the period of undertaking payback or a waiver request has been approved
by the PHS.
ANNUAL PAYBACK ACTIVITIES CERTIFICATION, FORM PHS 6031-1
The enclosed Annual Payback Activities Certification (APAC) form is the basic
communication between former Kirschstein-NRSA recipients and the PHS.
Regardless of the nature of your present activities, complete and return the
form. Do not hesitate to provide supplemental information or request
clarification of your obligation from the PHS agency that supported your
training.
SPECIAL INSTRUCTIONS FOR APAC
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
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
2 certifications,” etc. This form is available at:
http://grants.nih.gov/grants/forms.htm #training
.
SECTION I
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
payback or requesting an extension of the 2-year period in which to initiate
payback, sign and return the form; no further information is required. If the
APAC covers the second year after termination of your Kirschstein-NRSA
support, financial payback will be due 24 months after the termination date
unless a request for an extension of the payback initiation period or a payback
waiver is submitted and approved.
Item 2. Financial Payback: Those electing financial payback will be contacted
by the PHS with appropriate instructions.
Item 3. Extension: Reasons for an extension or break in service include such
things as physicians completing residency training, graduate students
completing degree requirements, temporary disability or substantial hardship.
This item should also be used to report participation in any of the NIH Loan
Repayment Programs (LRP). Participation in LRP will result in a deferral of the
NRSA obligation because concurrent payback under both LRP and NRSA is
not permissible. If requesting an extension because of LRP participation,
include the start and end date of your LRP in Section II.4.
Item 4. Engaged in Payback Service: This item includes regular payback
service (biomedical or behavioral health-related research, teaching, and/or
activities). For additional information on acceptable payback service, see the
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 06/15) Instructions Page 2 of 3
SECTION II
Item 1. Number of Months: Indicate the number of months and dates
(mm/dd/yyyy) engaged in payback service during this reporting period. Do not
include any service already reported on previous APACs submitted.
Item 4. Description of Duties: The description of regular service should
include sufficient information to serve as the basis for determination of
acceptability. It should include: (a) the specific activities (research, teaching,
health-related activities, etc.); (b) field of research/training duties; and (c) the
source(s) of salary supporting the activities. Include number of hours per week
if not full time and the dates covered by each activity, if different from those in
Section II, Item 1.
SECTION III
This section must be completed and signed by the supervisor(s) of record.
SECTION V
For those engaged in payback service, the APAC should be signed on or after
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 former Kirschstein-NRSA trainees and fellows and is authorized to collect
this information under Section 487 of the Public Health Service Act. Providing
your Social Security Number is voluntary and you will not be deprived of any
Federal rights, benefits or privileges for refusing to disclose it.
PREPRINTED INFORMATION
Address Verification: Until your payback obligation is completed, report
immediately any change in name or address to the Kirschstein-NRSA Payback
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.
Record of Payback Obligation: The legislative allowance, when applicable,
reflects the individual’s initial 12 months of support under the Kirschstein-NRSA
funding authority which on appointments or fellowship awards started prior to
June 10, 1993, was not subject to payback.* Service credited is obtained from
previous APAC reports.
PHS 6031-1 (Rev 06/15) Instructions
MAILING/E-MAIL
Return the completed APAC(s) with the necessary signatures, and one copy of
any attachment(s), no later than 30 days after the reporting period end date to
the address below. This item may also be sent via e-mail to the address listed
below. When the payback service or extension request is approved by PHS, a
copy of the APAC will be returned to you.
For any questions, please contact:
NRSA Payback Service Center
Office of Extramural Programs
OER/OD/National Institutes of Health
6011 Executive Boulevard, Suite 206, MSC 7650
Bethesda, MD 20892-7650
Phone: (301) 594-1835 or (866) 298-9371
NRSApaybackcenter@mail.nih.gov
Public reporting burden for this collection of information is estimated to average
20 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 address.
* Individuals in delinquent payback status prior to August 13, 1981, have a payback
obligation for the total amount of time of Kirschstein-NRSA support.
Privacy Act Statement. The NIH maintains application and grant records as
part of a system of records as defined by the Privacy Act: NIH 09-25-0255
ending
https://era.nih.gov/privacy-act-and-era.htm
.
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Completed 27 February 2020

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