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Phs-6031 FORM PHS 6031

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Form Approved Through 03/31/2020 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 1602 of the NIH Revitalization Act of
1993, which was signed into law on June 10, 1993,
contains provisions which substantially modify the service
payback requirements for individuals receiving Ruth L.
Kirschstein National Research Service Awards (NRSA).
These modifications apply to individuals beginning
Kirschstein-NRSA-supported appointments or fellowship
awards on or after June 10, 1993. 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 the new 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, research training, and/or health-related
activities that averages at least 20 hours per week
based on a full work year;
•
By engaging in an equal period of health-related
teaching 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 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. This service shall be initiated within 2 years after
termination of Kirschstein-NRSA support. The research,
teaching, and/or health-related activities 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 obligation due to 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
FUN
PHS 6031 (Rev. 08/18)
Page 1 of 3
PSC Publishing Services (301) 443-6740
EF
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
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-
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. 08/18)
Page 2 of 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:
Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the
Privacy Act: NIH 09-25-0225
https://era.nih.gov/privacy-act-and-era.htm
.
PHS 6031 (Rev. 08/18)
Page 3 of 3
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Phs-6031 FORM PHS 6031

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Completed 27 February 2020

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