## Information and Instructions for Completing a Termination Notice

***(Completed form should be mailed to the PHS awarding agency Grants
Management Office named in the Notice of Award)***

This form summarizes the information to be supplied by Ruth L.
Kirschstein National Research Service Award (NRSA) recipients on
termination of their award and for a limited period thereafter. This
form may also be used to document the termination of appointments to
non-NRSA institutional research training programs (e.g., T15), research
education awards (e.g., R25), and institutional career development
awards (e.g., K12). For non-NRSA recipients, please refer to specific
guidance on documenting the termination of appointments in the Funding
Opportunity Announcement, and in the terms and conditions of the Notice
of Award.

### All KirschsteinNRSA Recipients

\(1\) The attached Termination Notice (PHS 416-7) serves as the official
record of your training under a KirschsteinNRSA. This summary of work
accomplished, support period, stipends received, and post-training
activity is required of all recipients immediately after termination.
After securing proper signatures, forward the completed form to the
appropriate awarding office (National Institutes of Health (NIH)
Institute or Center or Agency for Healthcare Research and Quality
(AHRQ)). This form may be filled out online and then printed for
submission.

\(2\) Because the sponsoring Federal agencies are asked periodically to
review KirschsteinNRSA program impact in terms of career choices, you
may be contacted after the termination of this award, but no more
frequently than once every 2 years, to determine how the training
obtained has influenced your career.

### KirschsteinNRSA Postdoctoral Recipients with a Payback Obligation

\(1\) As specified in the Payback Agreement you signed at the time of
award, biomedical or behavioral health-related research, health-related
teaching, and/or health-related activities must begin within 2 years of
terminating KirschsteinNRSA support; otherwise, unless an extension of
the 2 year service initiation period or a waiver of the obligation is
granted, financial payback becomes due. Further details are given in the
[Payback
Agreement](http://grants.nih.gov/grants/funding/416/phs6031.doc) and the
National Research Service Awards section of the most recent version of
the NIH Grants Policy Statement found at:
<http://grants.nih.gov/grants/policy/policy.htm>. If you have any
questions, contact the awarding office that supported your training.

\(2\) To record your payback status and service, you will receive from
the sponsoring Federal agency an Annual Payback Activities Certification
(APAC) (PHS 6031-1) form one year after your termination date and
annually thereafter until your service obligation has been completed.

\(3\) You are required to keep the Federal funding agency informed of
your current address and telephone number until your total payback
obligation is satisfied. Report any change to the NRSA Payback Service
Center, Office of Extramural Programs, National Institutes of Health,
6011 Executive Boulevard, Suite 206, MSC 7650, Bethesda, MD 20892-7650;
(301) 594-1835; (866) 298-9371.

### Specific Instructions for Items on the Termination Notice

(Item 1) Where applicable, include in parentheses any maiden name or
other name used. This information is helpful in identifying past records
and publications.

(Item 2) Provide the complete grant or award number of the budget period
supporting your last year of research training, career development or
education (e.g., 5 T32 GM 60654-08).

(Item 3) Self-explanatory.

(Item 4) The last four digits of your Social Security Number are
requested under authority of the Public Health Service Act as amended
(42 USC 288). This information provides the sponsoring Federal agency
with vital information necessary for accurate identification and review
of terminated appointments and fellowships and, where applicable, to
establish and maintain an accurate payback record file. Providing this
portion of your Social Security Number is voluntary and you will not be
deprived of any Federal rights, benefits, or privileges for refusing to
disclose it.

(Item 5) Include the degree(s) sought or earned during the period of
support and the date all degree(s) requirements were (or will be)
completed.

(Item 6) Self-explanatory.

(Item 7) **For Kirschstein-NRSA Awards Only** \-- Provide information on
your total KirschsteinNRSA stipend support under the parent fellowship
or training grant of which the number in Item 2 is a part. For domestic
non-Federal institutions, the "Amount of Stipend" column must reflect
the stipend only. Individual fellows sponsored by (training at) Federal
or foreign institutions must include all money paid directly to them by
government check in the "Amount of Stipend" column. Note the stipend
amount must reflect only the Kirschstein-NRSA stipend. Do not include
any supplementation provided by other sources. Do **not** include any
other NRSA-awarded costs such as tuition or institutional allowance.

(Item 8) Self-explanatory.

(Item 9a) Please mark a single box under each of the three categories
that best describes your anticipated post-award position, activity, and
the organization with which you will be affiliated.

(Items 9b and 9c) Provide post-award title, address, and phone number,
if known.

(Item 10) **For Kirschstein-NRSA Awards Only** \-- Provide an address
where information regarding post-KirschsteinNRSA training may be sent.

(Item 11) **For Kirschstein-NRSA Awards Only** \-- Provide information
on prior support from other KirschsteinNRSA grants and awards and/or
National Health Service Corps (NHSC) scholarships for which you still
have a service obligation. If you are currently participating in the NIH
Loan Repayment Program, check "LRP." This information will be used to
develop a complete service obligation record.

(Item 12) In signing this form, I certify that the statements therein
are true and complete to the best of my knowledge. Willful provision of
false information is a criminal offense (U.S. Code, Title 18, Section
1001). I am aware that any false, fictitious, or fraudulent statement
may, in addition to other remedies available to the Government, subject
me to civil penalties under the Program Fraud and Civil Remedies Act of
1986 (45 CFR Part 79). Also, if I have a payback obligation, I
understand that payback service must begin within 2 years of terminating
my KirschsteinNRSA support; otherwise, financial payback becomes due,
unless an extension of the 2-year service initiation period or a waiver
of the obligation is granted. I also understand that if I fail to repay
both principal and interest, the Federal Government will take authorized
actions to collect the debt.

(Item 13) The sponsor of (for individual fellowship awards) or the
contact Program Director (for an institutional award) must sign and date
the form certifying that the research training information is correct.

(Item 14) **For Kirschstein-NRSA Awards Only** \-- A business official
of domestic non-Federal sponsoring institutions (with the knowledge and
authority to verify this information) must certify that the information
provided in Items 6 and 7 is correct according to institutional records.

NIH estimates that it will take 30 minutes to complete this form. This
includes time for reviewing the instructions, gathering needed
information, and completing and reviewing the form. 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. If you have comments regarding this burden estimate or
any other aspect of this burden, send comments to: NIH, Project
Clearance Office, 6705 Rockledge Drive MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925- 0002). *DO NOT RETURN THE COMPLETED FORM TO
THIS ADDRESS*.

<table style="width:100%;">
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<tbody>
<tr class="odd">
<td colspan="19">Form Approved Through 09/30/2011 OMB No. 0925-0002</td>
</tr>
<tr class="even">
<td colspan="8" rowspan="2"><p>Department of Health and Human
Services<br />
Public Health Service</p>
<h1 id="ruth-l.-kirschstein-national-research-service-award">Ruth L.
Kirschstein National Research Service Award</h1>
<h2 id="termination-notice">Termination Notice</h2></td>
<td colspan="11"><p>1. NAME OF FELLOW OR APPOINTEE <em>(Last, first,
middle</em>)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="11"><p>2. GRANT NO.</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="8"><p>3. NAME OF SPONSORING INSTITUTION</p>
<p>     </p></td>
<td colspan="5"><p>4. SOCIAL SECURITY<br />
NO.</p>
<p>XXX-XX-    </p></td>
<td colspan="6"><p>5. DEGREE(S) EARNED/ COMPLETION<br />
DATE(S)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="8">6. DATES OF SUPPORT UNDER THIS AWARD (Month, day,
year):</td>
<td colspan="6">FROM:      </td>
<td colspan="5">TO:      </td>
</tr>
<tr class="even">
<td colspan="19">7. TOTAL KIRSCHSTEIN-NRSA STIPEND RECEIVED AND NUMBER
OF MONTHS SUPPORTED UNDER THIS AWARD (See specific instructions for
Amount of Stipend)</td>
</tr>
<tr class="odd">
<td>YEAR OF SUPPORT</td>
<td colspan="2">AMOUNT OF STIPEND</td>
<td colspan="5">NUMBER OF<br />
Months Days</td>
<td colspan="3">YEAR OF SUPPORT</td>
<td colspan="6">AMOUNT OF STIPEND</td>
<td colspan="2">NUMBER OF<br />
Months Days</td>
</tr>
<tr class="even">
<td>1<sup>ST</sup> YEAR</td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">5<sup>TH</sup> YEAR</td>
<td colspan="6">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>2<sup>ND</sup> YEAR</td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">6<sup>TH</sup> YEAR</td>
<td colspan="6">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td>3<sup>RD</sup> YEAR</td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">7<sup>TH</sup> YEAR</td>
<td colspan="6">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>4<sup>TH</sup> YEAR</td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3"><strong>TOTALS</strong></td>
<td colspan="6">     </td>
<td>     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="19"><p>8. Provide a summary of training received and
research undertaken during fellowship or trainee tenure. List
publications, if any, resulting from the research during this period.
List grants and career awards pending and received. <em>If fellowship or
training appointment is being terminated early, state reason</em>.</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="10">9a. POST-AWARD INFORMATION: Please mark a single box in
each of the categories below.</td>
<td colspan="9" rowspan="3"><p>9b. POST-AWARD POSITION TITLE, FIELD,
NAME OF ORGANIZATION, CITY, AND STATE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="2">Type of Position</td>
<td colspan="4">Activity</td>
<td colspan="4">Organization</td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2"><p> Student</p>
<p> Resident/Clinical Fellow</p>
<p> Postdoctoral Researcher</p>
<p> Research Scientist (non-faculty)</p>
<p> Faculty: Tenure-Track</p>
<p> Faculty: Other</p>
<p> Clinical Staff/Private Practice</p>
<p> Unknown</p>
<p> Other:      </p></td>
<td colspan="4" rowspan="2"><p> Further Education/Training</p>
<p> Teaching</p>
<p> Research</p>
<p> Administration</p>
<p> Clinical Practice</p>
<p> Unknown</p>
<p> Other:      </p></td>
<td colspan="4" rowspan="2"><p> Academic</p>
<p> Industry</p>
<p> Government</p>
<p> Hospital</p>
<p> Non-profit</p>
<p> Unknown</p>
<p> Other:      </p></td>
</tr>
<tr class="even">
<td colspan="9">9c. TEL NO.      </td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="4"><p>10a. MAILING ADDRESS AFTER TERMINATION OF
THIS KIRSCHSTEIN-NRSA SUPPORT (Street, city, state, zip code)</p>
<p>     </p></td>
<td colspan="12">11. OTHER PHS SERVICE OBLIGATION SUPPORT</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">NHSC Scholarship: No of months:</td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Kirschstein-NRSA: No. of months:</td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3">Period of support:</td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td colspan="7">10b. TEL NO.      </td>
<td colspan="2"></td>
<td colspan="3">Grant No.:</td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="7">E-MAIL:      </td>
<td colspan="2"></td>
<td colspan="10">LRP</td>
</tr>
<tr class="odd">
<td colspan="12">12. SIGNATURE OF FELLOW OR APPOINTEE (See specific
instructions)</td>
<td colspan="7"><p>DATE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="19"><strong>13. Certification of Sponsor or Program
Director</strong>: that to the best of my knowledge all the above
information is correct.</td>
</tr>
<tr class="odd">
<td colspan="4">SIGNATURE</td>
<td colspan="4"><p>DATE</p>
<p>     </p></td>
<td colspan="11"><p>TYPED NAME OF SPONSOR OR PROGRAM DIRECTOR</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="19"><strong>14. Business Official’s Verification of Items 6
and 7.</strong> (Not applicable to individual fellows at Federal or
foreign institutions.)</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2">SIGNATURE</td>
<td colspan="4" rowspan="2"><p>DATE</p>
<p>     </p></td>
<td colspan="8" rowspan="2"><p>TYPED NAME OF BUSINESS OFFICIAL</p>
<p>     </p></td>
<td>TEL:</td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>FAX::</td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="19"><strong>15.</strong> <em>(For Government use only)</em>
<strong>The information provided in Items 6 and 7 is in agreement with
PHS records.</strong></td>
</tr>
<tr class="even">
<td colspan="4">SIGNATURE</td>
<td colspan="4"><p>DATE</p>
<p>     </p></td>
<td colspan="11"><p>TYPED NAME AND AWARDING OFFICE</p>
<p>     </p></td>
</tr>
</tbody>
</table>

PHS 416-7 (Rev. 9/08)

# Privacy Act Statement

The Public Health Service requests this information pursuant to
statutory authorities contained in Section 405(a) and 487 of the Public
Health Service Act, as amended (42 USC 284(b)(1)C and 288), and other
statutory authorities (42 USC 242(a), 280(b)(4), and 29 USC 670). The
information collected will facilitate postaward management and
evaluation of PHS programs. *Ruth L. Kirschtein National Research
Service Awardees agreed to complete and submit this form as part of the
Payback Agreement and Activation Notice signed when support started.
Information on the period of support and stipend received will be used
to verify and establish in the PHS the official record of the fellow's
or trainee's payback obligation to the Federal government.* The social
security number is requested to provide a reliable identifier that will
assist in establishing an accurate and complete record for each
individual. It is particularly useful in maintaining effective
communication with those individuals who have incurred payback
obligations through their participation in the Ruth L. Kirschstein
National Research Service Award program. Failure to provide the social
security number may seriously diminish PHS's capability to credit the
account of the proper trainee who is fulfilling the payback requirement
by either acceptable service and/or monetary repayment. Failure to
provide the social security number will not be a basis for withholding
benefits.

The PHS maintains application and grant records as part of a system of
records as defined by the Privacy Act: 09-25-0036, "Extramural Awards
and Chartered Advisory Committees." The Privacy Act of 1974 (5 USC 552a)
allows disclosures for "routine uses" and permissible disclosures.

Routine uses include:

1\. To the cognizant audit agency for auditing.

2\. To a Congressional office from a record of an individual in response
to an inquiry from the Congressional office made at the request of that
individual.

3\. To qualified experts, not within the definition of DHHS employees as
prescribed in DHHS regulations (45 CFR 5b.2) for opinions as part of the
application review process.

4\. To a Federal agency, in response to its request, in connection with
the letting of a contract or the issuance of a license, grant, or other
benefit by the requesting agency, to the extent that the record is
relevant and necessary to the requesting agency's decision on the
matter.

5\. To organizations in the private sector with whom PHS has contracted
for the purpose of collating, analyzing, aggregating, or otherwise
refining records in a system. Relevant records will be disclosed to such
a contractor, who will be required to maintain Privacy Act safeguards
with respect to such records.

6\. To the sponsoring organization in connection with the review of an
application or performance or administration under the terms and
conditions of the award, or in connection with problems that might arise
in performance or administration if an award is made.

7\. To the Department of Justice, to a court or other tribunal, or to
another party before such tribunal, when one of the following is a party
to litigation or has any interest in such litigation, and the DHHS
determines that the use of such records by the Department of Justice,
the tribunal, or the other party is relevant and necessary to the
litigation and would help in the effective representation of the
governmental party.

a\. the DHHS, or any component thereof;

b\. any DHHS employee in his or her official capacity;

c\. any DHHS employee in his or her individual capacity where the
Department of Justice (or the DHHS, where it is authorized to do so) has
agreed to represent the employee; or

d\. the United States or any agency thereof, where the DHHS determines
that the litigation is likely to affect the DHHS or any of its
components.

8\. A record may also be disclosed for a research purpose, when the
DHHS:

a\. has determined that the use or disclosure does not violate legal or
policy limitations under which the record was provided, collected, or
obtained;

b\. has determined that the research purpose (1) cannot be reasonably
accomplished unless the record is provided in individually identifiable
form, and (2) warrants the risk to privacy of the individual that
additional exposure of the record might bring;

c\. has secured a written statement attesting to the recipient's
understanding of, and willingness to abide by, these provisions; and

d\. has required the recipient to:

\(1\) Establish reasonable administrative, technical, and physical
safeguards to prevent unauthorized use or disclosure of the record;

\(2\) Remove or destroy the information that identifies the individual
at the earliest time at which removal or destruction can be accomplished
consistent with the purpose of the research project, unless the
recipient has presented adequate justification of a research or health
nature for retaining such information; and

\(3\) Make no further use or disclosure of the record, except (a) in
emergency circumstances affecting the health or safety of any
individual, (b) for use in another research project, under these same
conditions, and with written authorization of the DHHS, (c) for
disclosure to a properly identified person for the purpose of an audit
related to the research project, if information that would enable
research subjects to be identified is removed or destroyed at the
earliest opportunity consistent with the purpose of the audit, or (d)
when required by law.

The Privacy Act also authorizes discretionary disclosures where
determined appropriate by the PHS, including to law enforcement
agencies, to the Congress acting within its legislative authority, to
the Bureau of the Census, to the National Archives, to the General
Accounting Office, pursuant to a court order, or as required to be
disclosed by the Freedom of Information Act of 1974 (5 USC 552) and the
associated DHHS regulations (45 CFR Part 5).