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Phs6315 FORM PHS-6315

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
ASSURANCE OF COMPLIANCE BY
SUB-AWARD RECIPIENTS
Regarding Procedures for Dealing With and Reporting
Research Misconduct Allegations
FORM APPROVED: OMB No. 0937-0198; Expires: 05/31/2020
See Statement of Burden Below
INSTITUTIONAL OFFICIAL'S NAME
INSTITUTIONAL OFFICIAL'S TITLE
Please make any mailing changes in the space to the
right:
Place mailing label here.
NAME OF INSTITUTION
MAILING ADDRESS OF INSTITUTIONAL OFFICIAL
NAME OF INSTITUTION FROM WHICH PHS FUNDS ARE RECEIVED AS SUBRECIPIENT
Section I. ORI Assurance of Compliance for Sub-Award recipients
Institutions with U.S. Public Health Service (PHS) supported biomedical or behavioral research, research training or activities related
to that research or research training must provide PHS with an assurance of compliance with the Public Health Service Policies on
Research Misconduct, 42 C.F.R. Part 93.
Section II. Certification
I certify that:
(a) This institution has written policies and procedures in compliance with 42 C.F.R. Part 93 for inquiring into and investigating
allegations of research misconduct; and
(b) This institution is in compliance with its own policies and procedures and the requirements of 42 C.F.R. Part 93.
Name of Official:
Title:
(c) The person responsible for administering the institutions procedures, compliant with 42 CFR 93.300(b) is? (At some Institutions
this person is called the Research Integrity Officer or RIO).
(d) The person responsible for “fostering a research environment that promotes the responsible conduct of research” in
compliance with 42 CFR 93.300(c) is? At some institutions this person is called the RCR coordinator or administrator.
Name of Official:
Title:
Official Certifying for Institution
NAME OF OFFICIAL (Please type)
TITLE
SIGNATURE
DATE
TELEPHONE NUMBER
( )
FAX NUMBER
( )
E-MAIL ADDRESS OF OFFICIAL:
PHS-6315 (Rev. 11/19) PAGE 1
PSC Publishing Services (301) 443-6740
EF
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STATEMENT OF BURDEN
Public reporting burden for this collection of information is estimated to
average 5 minutes to complete the form, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the
data needed and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to:
OS Reports Clearance Officer, Hubert H. Humphrey Building, Room 503-H,
200 Independence Avenue, S.W., Washington, D.C. 20201 (Attn: PRA)
and to: Office of Management and Budget, Paperwork Reduction Project
(0937-0198) Washington, D.C. 20502. Please do not return this form to
either of these addresses.
RETURN THIS FORM TO:
Robin Parker
Assurance Program
Office of Research Integrity
1101 Wootton Parkway, Suite 240
Rockville, MD 20852
Phone: (240) 453-8407
E-Mail:
PHS-6315 (Rev. 11/19) PAGE 2
ORI_Assurance@hhs.gov
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Completed 27 February 2020

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