Instructions for PHS 2271 Form Approved Through 11/30/2010

Revised 11/07 OMB No. 0925-0001

# U.S. Department of Health and Human Services Public Health Service {#u.s.-department-of-health-and-human-services-public-health-service .title1}

## Information and Instructions for Completing Statement of Appointment (Form PHS 2271) {#information-and-instructions-for-completing-statement-of-appointment-form-phs-2271 .title2}

The Public Health Service (PHS) estimates that it will take 15 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 the
amount of time it takes to complete this form or any other aspects of
this collection of information, including suggestions for reducing this
burden, send comments to: NIH, Project Clearance Office, 6705 Rockledge
Drive MSC 7974, Bethesda, MD 20592-7974, ATTN: PRA (0925-0001). **Do not
return the completed form to this address.**

# I. INTRODUCTION

This form is to be used to appoint individuals as trainees to
institutional Ruth L. Kirschstein-National Service Research Award
(Kirschstein-NRSA) programs (e.g., T32, T34, T35) and applicable
non-NRSA institutional research training programs (e.g., T15). It can
also be used to document the appointment of scholars to institutional
career development awards (e.g., K12) and individual participants to
research education awards (e.g., R25).

Please read carefully the following instructions, including the Privacy
Act Statement at the end of this document. All items on the form must be
completed unless otherwise indicated in these instructions.

# II. GENERAL INSTRUCTIONS

## A. Definitions:

**[Types of Awards]{.underline}**

> **Kirschstein-NRSA.** Awards that provide undergraduate, predoctoral,
> and postdoctoral research training support under the authority of
> Section 487 of the PHS Act (42 USC 288). All Kirschstein-NRSA trainees
> must meet specific citizenship requirements -- for details, see Item
> 8.
>
> **Non-NRSA Research Training.** Awards that provide predoctoral and
> postdoctoral research training support through non-NRSA funding
> authorities. These training programs generally do not have the same
> provisions and requirements as Kirschstein-NRSA awards (e.g., specific
> citizenship requirements).
>
> **Career Development.** Awards that provide doctoral-level
> investigators an opportunity to enhance their research careers.
> Individuals appointed to institutional career development awards must
> meet specific citizenship requirements---for details, see Item 8.
>
> **Research Education.** Awards that provide support for programs
> intended to attract investigators to a specific field of study.
> Individuals appointed to research education award programs may or may
> not be subject to specific citizenship requirements---for details, see
> Item 8.

**[Types of Appointments]{.underline}**

> **Trainee.** A person appointed to and supported by an institutional
> Kirschstein-NRSA or non-NRSA research training award.
>
> **Scholar.** A person appointed to and supported by an institutional
> career development award.
>
> **Participant.** A person appointed to and supported by a research
> education award.

## B. Application

A "Statement of Appointment" form covers the support of an individual
for a particular budget period and is required for each new appointment,
reappointment, or amended appointment of an individual receiving
stipend, tuition costs, or travel expenses as a trainee under a
Kirschstein-NRSA or other applicable PHS institutional training grant.
This form may also be used to document the salary and other support
provided to an individual as a scholar or participant under a career
development or research education program award in which the institution
selects and appoints the individual. The form (which is signed by both
the individual and the Program Director) must be completed and submitted
to PHS at the time the individual starts the appointment or
reappointment, or, in the case of an amendment, as soon as the change
occurs. If there are multiple Program Directors on the award, the
contact PD should sign.

For **new** postdoctoral trainees appointed to Kirschstein-NRSA
institutional grants, a signed and dated [payback
agreement](http://grants.nih.gov/grants/funding/416/phs6031.doc) must be
submitted with this appointment form before a stipend or other allowance
may be paid.

## C. Submission

The original should be sent to the awarding component. A copy should
also be given to the trainee, scholar, or participant, the Program
Director, and Business Official.

# III. ITEM-BY-ITEM INSTRUCTIONS

**Item 1. PHS Grant Number.** Insert the entire PHS Grant Number as
shown on the particular Notice of Grant Award from which funds are
provided, e.g., 5 T32 GM12453-03 would be listed as\
Type: 5; Activity Code: T32; ID Serial Number: GM12453-03.

**Item 2. Trainee/Scholar/Participant Name.** Include maiden name or
other names in parentheses where applicable.

**Item 3. Sex.** Self-explanatory.

**Item 4. Type of Action.**

**New Appointment:** When an individual has not been previously
supported by this training grant.

**Reappointment:** When an individual was supported by this grant during
a previous budget period, the appointment covered by this form is
designated a reappointment. Skip the shaded items if the information
provided will be the same as that reported during the prior budget
period. Always complete the non-shaded items.

**Amendment:** "Amendment" pertains only to a change of item 2 (Name); 9
(Permanent Mailing Address); 15 (Appointment Period); or 20 (Support
from this Grant) during a period of appointment for which a "Statement
of Appointment" form has already been submitted. Amendments must be
submitted as soon as the change occurs. Complete only items 1, 2, 4, 6,
22, 23, and the item(s) to be amended.

**Item 5. Prior NRSA Support.** Individuals being appointed to a
Kirschstein-NRSA institutional grant for the first time or being
reappointed after a break in support must indicate if they have received
prior Kirschstein-NRSA support from either an individual award or
institutional grant. If yes, specify on the form the dates of support,
the level (pre- or post-), the mechanism (individual award or
institutional grant), and the grant number, if known. (See the Program
Guidelines for limitations on total period of support.)

**Item 6. Social Security Number.** Trainees/scholars/participants are
asked to voluntarily provide the last four digits of their Social
Security Numbers. This information provides the agency with vital
information necessary for accurate identification and review of
appointments and for management of PHS grant programs. See the Privacy
Act Statement at the end of these instructions for further information
concerning this request.

**Item 7. Birthdate.** Self-explanatory.

**Item 8. Citizenship.** Check the box corresponding to the trainee's,
scholar's, or participant's citizenship and visa status. If not a U.S.
citizen, list the country of citizenship.

A **noncitizen national** is an individual who, although not a citizen
of the United States, owes permanent allegiance to the United States.
Individuals in this category are generally born in lands which are not
States, but which are under U.S. sovereignty, jurisdiction, or
administration (e.g., American Samoa).

Kirschstein-NRSA trainees and institutional career development scholars
must be U.S. citizens, non-citizen nationals, or permanent residents of
the United States. Individuals on temporary or student visas are not
eligible. Trainees or scholars in these programs who are permanent
residents of the U.S. must submit a notary's signed statement with this
appointment form certifying that they have (1) a Permanent Resident Card
(USCIS Form I-551), or (2) other legal verification of such status.

Trainees in non-NRSA research training programs and participants in
research education award programs should consult the applicable Funding
Opportunity Announcement (FOA) for citizenship requirements.

**Item 9. Permanent Mailing Address.** Give an address where the
appointed individual can be reached by mail **after** completion of the
program. (Do not give present address unless it is considered permanent
as defined above.)

**Items 10-13. Race/Ethnicity/Disability/Disadvantaged Background.**
Responses to these items will help provide statistical information on
the participation of individuals from diverse groups in Public Health
Service (PHS) programs and identify inequities in terms of recruitment
and retention based on race, ethnicity, disability and/or disadvantaged
background.

Trainees, scholars, and participants are strongly encouraged to provide
this information, however declining to do so will in no way affect their
appointments.

This information will be retained by the PHS in accordance with and
protected by the Privacy Act of 1974.
Racial/ethnic/disability/background data are confidential and all
analyses utilizing the data will report aggregate statistical findings
only and will not identify individuals. (See the Privacy Act Statement
at the end of these instructions for more information.)

**10. Are you Hispanic (or Latino)?**

**Hispanic or Latino:** A person of Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish culture or origin, regardless of
race. The term, "Spanish origin," can be used in addition to "Hispanic
or Latino".

**11. What is your racial background?\
Check one or more.**

**American Indian or Alaska Native.** A person having origins in any of
the original peoples of North, Central, or South America and maintains
tribal affiliation or community.

**Asian.** A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.

**Black or African American.** A person having origins in any of the
black racial groups of Africa. Terms such as "Haitian" or "Negro" can be
used in addition to "Black or African American."

**Native Hawaiian or Other Pacific Islander.** A person having origins
in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.

**White.** A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.

**12. Do you have a disability?**

**Disability:** A physical or mental impairment that substantially
limits one or more major life activities.

**13. Are you from a disadvantaged background?**

**Disadvantaged Background:** An individual is considered to be from a
disadvantaged background if he or she:

1\. Comes from a family with an annual income below established
low-income thresholds, published by the U.S. Bureau of the Census;
adjusted annually for changes in the Consumer Price Index; and adjusted
by the Secretary for use in all health professions programs. The
Secretary periodically publishes these income levels at
[http://aspe.hhs.gov/poverty/
index.shtml](http://aspe.hhs.gov/poverty/index.shtml). Individuals
falling in this category must have qualified for Federal disadvantaged
assistance or have received Health Professional Student Loans (HPSL),
Loans for Disadvantaged Student Program, or scholarships from the U.S.
Department of Health and Human Services under the Scholarship for
Individuals with Exceptional Financial Need.

2\. Comes from a social, cultural, or educational environment, such as
that found in certain rural or inner-city environments, that has
demonstrably and recently directly inhibited the acquisition of the
knowledge, skills, and abilities necessary to develop and participate in
a research career. This category is most applicable to high school and
perhaps undergraduate students, but more difficult to justify for
individuals beyond that level of achievement.

**Item 14. Field of Training (FOT).** Provide a single numeric FOT code
from the list below that best fits the research training that will be
provided during the appointment. Use the subcode (nonbold lowercase)
unless the broader category (bold uppercase) fits best.

1000 I. Predominantly Non-Clinical or Lab-Based Research Training

1100 BIOCHEMISTRY

1110 Biological Chemistry

1120 Bioenergetics

1130 Enzymology

1140 Metabolism

1200 BIOENGINEERING

1210 Bioelectric/Biomagnetic

1220 Biomaterials

1230 Biomechanical Engineering

1240 Imaging

1250 Instrumentation and Devices

1260 Mathematical Modeling

1270 Medical Implant Science

1280 Nanotechnology

1290 Rehabilitation Engineering

1310 Tissue Engineering

1400 BIOPHYSICS

1410 Kinetics

1420 Spectroscopy

1430 Structural Biology

1440 Theoretical Biophysics

1500 BIOTECHNOLOGY

1510 Applied Molecular Biology

1520 Bioprocessing and Fermentation

1530 Metabolic Engineering

1600 CELL AND DEVELOPMENTAL BIOLOGY

1610 Cell Biology

1620 Developmental Biology

1700 CHEMISTRY

1710 Analytical Chemistry

1720 Bioinorganic Chemistry

1730 Bioorganic Chemistry

1740 Biophysical Chemistry

1750 Medicinal Chemistry

1760 Physical Chemistry

1770 Synthetic Chemistry

1900 ENVIRONMENTAL SCIENCES

2000 GENETICS

2010 Behavioral Genetics

2020 Developmental Genetics

2030 Genetic Epidemiology

2040 Genetics of Aging

2050 Genomics

2060 Human Genetics

2070 Molecular Genetics

2080 Population Genetics

2200 IMMUNOLOGY

2210 Asthma and Allergic Mechanisms

2220 Autoimmunity

2230 Immunodeficiency

2240 Immunogenetics

2250 Immunopathology

2260 Immunoregulation

2270 Inflammation

2280 Structural Immunology

2290 Transplantation Biology

2310 Vaccine Development

2400 MICROBIOLOGY AND INFECTIOUS DISEASES

2410 Bacteriology

2420 Etiology

2430 HIV/AIDS

2440 Mycology

2450 Parasitology

2460 Pathogenesis of Infectious Diseases

2470 Virology

2600 MOLECULAR BIOLOGY

2800 NEUROSCIENCE

2810 Behavioral Neuroscience

2820 Cellular neuroscience

2830 Cognitive neuroscience

2840 Communication Neuroscience

2850 Computational Neuroscience

2860 Developmental Neuroscience

2870 Molecular Neuroscience

2880 Neurochemistry

2890 Neurodegeneration

2910 Neuropharmacology

2920 Systems/Integrative Neuroscience

3100 NUTRITIONAL SCIENCES

3200 PHARMACOLOGY

3210 Molecular Pharmacology

3220 Pharmacodynamics

3230 Pharmacogenetics

3240 Toxicology

3300 PHYSIOLOGY

3310 Aging

3320 Anesthesiology (basic science)

3330 Endocrinology (basic science)

3340 Exercise Physiology (basic science)

3350 Integrative Biology

3360 Molecular Medicine

3370 Physiological Optics

3380 Reproductive Physiology

3500 PLANT BIOLOGY

3600 PSYCHOLOGY, NON-CLINICAL

3610 Behavioral Communication Sciences

3620 Behavioral Medicine (non-clinical)

3630 Cognitive Psychology

3640 Developmental and Child Psychology

3650 Experimental & General Psychology

3660 Mind-Body Studies

3680 Neuropsychology

3690 Personality and Emotion

3710 Physiological Psychology & Psychobiology

3720 Psychology of Aging

3730 Psychometrics

3740 Psychophysics

3750 Social Psychology

3900 PUBLIC HEALTH

3910 Disease Prevention and Control

3920 Epidemiology

3930 Health Economics

3940 Health Education

3950 Health Policy Research

3960 Health Services Research

3970 Occupational and Environmental Health

4100 RADIATION, NON-CLINICAL

4110 Nuclear Chemistry

4120 Radiation Physics

4130 Radiobiology

4200 SOCIAL SCIENCES

4210 Anthropology

4220 Bioethics

4230 Demography & Population Studies

4240 Economics

4250 Education

4260 Language and Linguistics

4270 Sociology

4400 STATISTICS AND/OR RESEARCH METHODS AND/OR INFORMATICS

4410 Biostatistics and/or Biometry

4420 Bioinformatics

4430 Computational Science

4440 Information Science

4450 Clinical Trials Methodology

4600 TRAUMA, NON CLINICAL

5000 OTHER, Predominantly Non-Clinical or Lab-Based Research Training

6000 II. Predominantly Clinical Research Training (can include any
degree)

6100 ALLIED HEALTH

6110 Audiology

6120 Community Psychology

6130 Exercise Physiology (clinical)

6140 Medical Genetics

6150 Occupational Health

6160 Palliative Care

6170 Physical Therapy

6180 Pharmacy

6190 Social Work

6210 Speech-language Pathology

6211 Rehabilitation

6400 DENTISTRY

6500 CLINICAL DISCIPLINES

6510 Allergy

6520 Anesthesiology

6530 Behavioral Medicine (clinical)

6540 Cardiovascular Diseases

6550 Clinical Laboratory Medicine

6560 Clinical Nutrition

6570 Clinical Pharmacology

6580 Complementary and Alternative Medicine

6590 Clinical Psychology

6610 Connective Tissue Diseases

6620 Dermatology

6630 Diabetes

6640 Gastroenterology

6650 Endocrinology

6660 Immunology

6670 Gene Therapy (clinical)

6680 Geriatrics

6690 Hematology

6710 HIV/AIDS

6820 Infectious Diseases

6830 Liver Diseases

6840 Metabolic Diseases

6850 Nephrology

6860 Neurology

6870 Ophthalmology

6880 Nuclear Medicine

6890 OB-GYN

6910 Oncology

6920 Orthopedics

6930 Otorhinolarynology

6940 Preventive Medicine

6950 Radiation, Interventional

6960 Pulmonary Diseases

6970 Radiology, Diagnostic

6980 Rehabilitation Medicine

6990 Psychiatry

7110 Surgery

7120 Trauma

7130 Urology

7300 PEDIATRIC DISCIPLINES

7310 Pediatric Endocrinology

7320 Pediatric Hematology

7330 Pediatric Oncology

7340 Pediatric, Prematurity & Newborn

7500 NURSING

7700 VETERINARY MEDICINE

8000 OTHER, Predominantly Clinical Research Training

**Item 15. Period of this Appointment.** The period shown in most cases
will be 12 months. Appointment periods may exceed 12 months in rare
cases and only with prior approval from the PHS. The amount of the
stipend/salary and tuition for each full period of appointment must be
obligated from funds available at the time the appointment begins,
unless other arrangements have been made with PHS.

Other instructions should be requested where institutional accounting
practice precludes obligations of stipend/salary and tuition in the
amount required for the full appointment period.

**Item 16. Education.** List undergraduate, master's, and doctoral
degrees and the month and year earned.

**Item 17. Specialty Boards.** If applicable, select a specialty from
the attached list. If not applicable, indicate N/A.

**Items 18-19. Degrees Sought.** Provide the degree sought under the
award. Indicate whether the appointee is in a dual degree program (e.g.,
M.D./Ph.D.).

Include the date that all degree requirements are expected to be
completed.

**Item 20. Support for Period of Appointment.** Indicate the total
amount the appointee expects to receive from the grant during the
appointment period. For trainees, provide stipend amount, tuition/fees,
and travel. For career development scholars and research education award
participants, report only the salary or subsistence allowance to be
received from the grant, on the line for stipend/salary/other
compensation.

**Item 21. Statement of Nondelinquency on U.S. Federal Debt.** A
"Statement of Nondelinquency on Federal Debt" is required for each
particular appointment period and is to be completed by each individual
(trainee) appointed to receive financial support under a PHS
institutional training grant.

If the prospective trainee is delinquent on Federal debt, the PHS must
review the explanation required to be provided on, or attached to, the
form. In such case the PHS shall (a) take such information into account
when determining whether the prospective trainee is responsible with
respect to that appointment, and (b) consider not approving the
appointment until payment is made or satisfactory arrangements are made
with the agency to whom the debt is owed.

Therefore, it may be necessary for the PHS to contact the prospective
trainee before the appointment can be approved to confirm the status of
the debt and ascertain the payment arrangements for its liquidation.
Individuals failing to liquidate indebtedness to the Federal Government
in a businesslike manner place themselves at risk of not receiving PHS
financial assistance.

The PHS awarding component shall notify the sponsoring institution in
writing of its decision regarding the approval of a prospective
appointee where this form discloses delinquency on Federal debt.

The trainee must check the appropriate box. If the "Yes" box is checked,
please provide an explanation in the space provided. The question
applies only to the person requesting financial assistance, and does not
apply to the person who signs the form as the Program Director.

Examples of Federal Debt include delinquent taxes, audit disallowances,
guaranteed or direct student loans, FHA loans, business loans, and other
miscellaneous administrative debts. For purposes of this certification,
the following definitions of "delinquency" apply:

• For direct loans and fellowships (whether awarded directly to the
applicant by the Federal Government or by an institution using Federal
funds), a debt more than 31 days past due on a scheduled financial
payment. (This definition excludes service payback under a National
Research Service Award.)

• For guaranteed and insured loans, recipients of a loan guaranteed by
the Federal Government that the Federal Government has repurchased from
a lender because the borrower breached the loan agreement and is in
default.

• For grants, organizations in receipt of a "Notice of Grants Cost
Disallowance" which have not repaid the disallowed amount or which have
not resolved the disallowance. (This definition excludes disallowance in
an "appeal" status.)

**Item 22. Certification and Signature of Appointee.** Self-explanatory.

**Item 23. Certification, Signature, and Address of Program Director.**
Self-explanatory.

##   {#section .privacyact-title .unnumbered}

##  {#section-1 .privacyact-title}

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<tbody>
<tr class="odd">
<td colspan="20"><p>Form Approved Through 11/30/2010</p>
<p>OMB No. 0925-0001</p></td>
</tr>
<tr class="even">
<td colspan="7"><p>Department of Health and Human Services</p>
<p>Public Health Services</p>
<h2 id="statement-of-appointment" class="FormHeading2">Statement of
Appointment</h2>
<p>(Please Type)</p></td>
<td colspan="13"><em><strong>Follow attached instructions
carefully.</strong></em> Submit this form at the time the individual is
appointed, is reappointed, or the reported appointment is amended.
Return this form to the PHS awarding component. For new postdoctoral
trainees under NRSA, signed and dated payback agreement
<strong>must</strong> accompany this form.</td>
</tr>
<tr class="odd">
<td colspan="7">1. PHS GRANT NUMBER</td>
<td colspan="12">2. APPOINTEE’S NAME <em>(Last, first,
initial)</em></td>
<td>3. SEX</td>
</tr>
<tr class="even">
<td><p>Type</p>
<p>     </p></td>
<td><p>Activity</p>
<p>     </p></td>
<td colspan="5"><p>ID Serial No.</p>
<p>     </p></td>
<td colspan="12">     </td>
<td> M F</td>
</tr>
<tr class="odd">
<td colspan="12" rowspan="2"><p>4. TYPE OF ACTION <em>(Check only one
type)</em></p>
<p> NEW appointment (NOT previously supported by this grant)</p>
<p> REAPPOINTMENT (Previously supported by this grant)</p>
<p> AMENDMENT of items checked: 2 9 15 20</p></td>
<td colspan="8"><p>5. PRIOR NRSA SUPPORT <em>(Individual or
institutional)</em></p>
<blockquote>
<p> NO YES (If “Yes,” see instructions)</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="8">     </td>
</tr>
<tr class="odd">
<td colspan="12"><p>6. SOCIAL SECURITY NO.</p>
<p>XXX-XX-     </p></td>
<td colspan="8"><p>7. BIRTHDATE <em>(Month, day, year)</em></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="12" rowspan="2"><p>8. CITIZENSHIP <em>(See
instructions)</em></p>
<p> U.S. Citizen or Noncitizen National</p>
<p>Non-U.S. Citizen</p>
<p> With a Permanent U.S. Resident Visa (“Green Card”)</p>
<p> With a Temporary U.S. Visa</p>
<p>If not a U.S. citizen, of which country are you a citizen?</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8"><p>9. PERMANENT MAILING ADDRESS</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="2"><blockquote>
<p>E-mail</p>
</blockquote></td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="20">10. Are you Hispanic (or Latino)? YES NO Do Not Wish to
Provide</td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="7"><p>11. What is your racial background?
<em>Check one or more</em></p>
<blockquote>
<p> American Indian or Alaska Native</p>
<p> Native Hawaiian or other Pacific Islander</p>
<p> Asian</p>
<p> Black or African American</p>
<p> White</p>
<p> Do Not Wish to Provide</p>
</blockquote></td>
<td colspan="12">12. Do you have a disability?</td>
</tr>
<tr class="even">
<td colspan="12"><blockquote>
<p> YES NO Do Not Wish to Provide</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="12">If yes, which of the following categories describe your
disability(ies):</td>
</tr>
<tr class="even">
<td colspan="8"><blockquote>
<p> Hearing</p>
</blockquote></td>
<td colspan="4"><blockquote>
<p> Mobility/Orthopedic Impairment</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="8"><blockquote>
<p> Visual</p>
</blockquote></td>
<td colspan="4"><blockquote>
<p> Other</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="12">13. Are you from a disadvantaged background?</td>
</tr>
<tr class="odd">
<td colspan="12"><blockquote>
<p> YES NO Do Not Wish to Provide</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="12">14. FIELD OF RESEARCH TRAINING OR CAREER DEVELOPMENT
<em>(for this appointment)</em></td>
<td colspan="8">15. PERIOD OF APPOINTMENT <em>(Month, day,
year)</em></td>
</tr>
<tr class="odd">
<td colspan="3"><blockquote>
<p>Enter a 4 digit code from instructions:</p>
</blockquote></td>
<td>  </td>
<td></td>
<td>  </td>
<td></td>
<td colspan="2">  </td>
<td></td>
<td>  </td>
<td></td>
<td colspan="5">From:      </td>
<td colspan="3">To:      </td>
</tr>
<tr class="even">
<td colspan="20">16. EDUCATION – AFTER HIGH SCHOOL <em>(Indicate all
academic and professional education. For foreign degrees, give U.S.
equivalent.)</em></td>
</tr>
<tr class="odd">
<td colspan="10"><p>(a) Name of Institution and Location</p>
<p>(List most recent first)</p></td>
<td colspan="5"><p>(b) Degree(s)</p>
<p>Received</p></td>
<td colspan="3">(c) Major Field</td>
<td colspan="2">(d) Minor Field</td>
</tr>
<tr class="even">
<td colspan="10"></td>
<td colspan="3">Degree</td>
<td colspan="2">Mo./Yr.</td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="10">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="10">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="10">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
</tr>
</tbody>
</table>

PHS 2271 (Rev. 11/07) Page 1 of 2

+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 17\. NAME OF          |   |   |   |   |   |   |                 |         |
| SPECIALTY BOARDS *(if |   |   |   |   |   |   |                 |         |
| applicable)*          |   |   |   |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 18\. DEGREE(S) SOUGHT |   | I |   |   |   |   |                 |         |
| YES NO                |   | f |   |   |   |   |                 |         |
|                       |   | y |   |   |   |   |                 |         |
|                       |   | e |   |   |   |   |                 |         |
|                       |   | s |   |   |   |   |                 |         |
|                       |   | , |   |   |   |   |                 |         |
|                       |   | i |   |   |   |   |                 |         |
|                       |   | n |   |   |   |   |                 |         |
|                       |   | d |   |   |   |   |                 |         |
|                       |   | i |   |   |   |   |                 |         |
|                       |   | c |   |   |   |   |                 |         |
|                       |   | a |   |   |   |   |                 |         |
|                       |   | t |   |   |   |   |                 |         |
|                       |   | e |   |   |   |   |                 |         |
|                       |   | t |   |   |   |   |                 |         |
|                       |   | y |   |   |   |   |                 |         |
|                       |   | p |   |   |   |   |                 |         |
|                       |   | e |   |   |   |   |                 |         |
|                       |   | \ |   |   |   |   |                 |         |
|                       |   | o |   |   |   |   |                 |         |
|                       |   | f |   |   |   |   |                 |         |
|                       |   | d |   |   |   |   |                 |         |
|                       |   | e |   |   |   |   |                 |         |
|                       |   | g |   |   |   |   |                 |         |
|                       |   | r |   |   |   |   |                 |         |
|                       |   | e |   |   |   |   |                 |         |
|                       |   | e |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| Are you in a dual     |   |   |   |   |   |   |                 |         |
| degree program (e.g., |   |   |   |   |   |   |                 |         |
| M.D./Ph.D.)? YES NO   |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 19\. EXPECTED         |   |   |   |   |   |   |                 |         |
| COMPLETION DATE OF    |   |   |   |   |   |   |                 |         |
| DEGREE REQUIREMENTS   |   |   |   |   |   |   |                 |         |
| *(if applicable)*     |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 20\. SUPPORT FOR      |   |   |   |   |   |   |                 |         |
| PERIOD OF APPOINTMENT |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| TYPE                  |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | T |   |   |   |                 |         |
|                       |   |   | o |   |   |   |                 |         |
|                       |   |   | t |   |   |   |                 |         |
|                       |   |   | a |   |   |   |                 |         |
|                       |   |   | l |   |   |   |                 |         |
|                       |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | f |   |   |   |                 |         |
|                       |   |   | o |   |   |   |                 |         |
|                       |   |   | r |   |   |   |                 |         |
|                       |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | t |   |   |   |                 |         |
|                       |   |   | h |   |   |   |                 |         |
|                       |   |   | i |   |   |   |                 |         |
|                       |   |   | s |   |   |   |                 |         |
|                       |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | G |   |   |   |                 |         |
|                       |   |   | r |   |   |   |                 |         |
|                       |   |   | a |   |   |   |                 |         |
|                       |   |   | n |   |   |   |                 |         |
|                       |   |   | t |   |   |   |                 |         |
|                       |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | * |   |   |   |                 |         |
|                       |   |   | ( |   |   |   |                 |         |
|                       |   |   | O |   |   |   |                 |         |
|                       |   |   | m |   |   |   |                 |         |
|                       |   |   | i |   |   |   |                 |         |
|                       |   |   | t |   |   |   |                 |         |
|                       |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | c |   |   |   |                 |         |
|                       |   |   | e |   |   |   |                 |         |
|                       |   |   | n |   |   |   |                 |         |
|                       |   |   | t |   |   |   |                 |         |
|                       |   |   | s |   |   |   |                 |         |
|                       |   |   | ) |   |   |   |                 |         |
|                       |   |   | * |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| > Stipend / Salary /  |   |   | > |   |   |   |                 |         |
| > Other Compensation  |   |   |   |   |   |   |                 |         |
|                       |   |   | \ |   |   |   |                 |         |
|                       |   |   | $ |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| > Tuition/fees        |   |   | > |   |   |   |                 |         |
| > *(estimated)*       |   |   |   |   |   |   |                 |         |
|                       |   |   | \ |   |   |   |                 |         |
|                       |   |   | $ |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| > Travel              |   |   | > |   |   |   |                 |         |
| > *(estimated)*       |   |   |   |   |   |   |                 |         |
|                       |   |   | \ |   |   |   |                 |         |
|                       |   |   | $ |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| TOTAL                 |   |   | > |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   | \ |   |   |   |                 |         |
|                       |   |   | $ |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 21\. STATEMENT OF     |   |   |   |   |   |   |                 |         |
| NONDELINQUENCY ON     |   |   |   |   |   |   |                 |         |
| U.S. FEDERAL DEBT. Is |   |   |   |   |   |   |                 |         |
| the appointee         |   |   |   |   |   |   |                 |         |
| delinquent on the     |   |   |   |   |   |   |                 |         |
| repayment of any U.S. |   |   |   |   |   |   |                 |         |
| Federal debt(s)?      |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| NO YES *(If "Yes,"    |   |   |   |   |   |   |                 |         |
| please explain        |   |   |   |   |   |   |                 |         |
| below.)*              |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 22\. CERTIFICATION    |   |   |   |   | \ |   |                 | \(b\)   |
| AND ACCEPTANCE: I     |   |   |   |   | ( |   |                 | DATE    |
| certify that the      |   |   |   |   | a |   |                 |         |
| statements herein are |   |   |   |   | \ |   |                 |         |
| true and complete to  |   |   |   |   | ) |   |                 |         |
| the best of my        |   |   |   |   | S |   |                 |         |
| knowledge and that I  |   |   |   |   | I |   |                 |         |
| will comply with all  |   |   |   |   | G |   |                 |         |
| applicable Public     |   |   |   |   | N |   |                 |         |
| Health Service terms  |   |   |   |   | A |   |                 |         |
| and conditions        |   |   |   |   | T |   |                 |         |
| governing my          |   |   |   |   | U |   |                 |         |
| appointment. I am     |   |   |   |   | R |   |                 |         |
| aware that any false, |   |   |   |   | E |   |                 |         |
| fictitious or         |   |   |   |   | O |   |                 |         |
| fraudulent statements |   |   |   |   | F |   |                 |         |
| or claims may subject |   |   |   |   | A |   |                 |         |
| me to criminal,       |   |   |   |   | P |   |                 |         |
| civil, or             |   |   |   |   | P |   |                 |         |
| administrative        |   |   |   |   | O |   |                 |         |
| penalties.            |   |   |   |   | I |   |                 |         |
|                       |   |   |   |   | N |   |                 |         |
|                       |   |   |   |   | T |   |                 |         |
|                       |   |   |   |   | E |   |                 |         |
|                       |   |   |   |   | E |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| 23\. This individual  |   |   |   |   | \ |   |                 | \(b\)   |
| is qualified for this |   |   |   |   | ( |   |                 | DATE    |
| program and is        |   |   |   |   | a |   |                 |         |
| eligible to receive   |   |   |   |   | \ |   |                 |         |
| financial support for |   |   |   |   | ) |   |                 |         |
| the period specified  |   |   |   |   | S |   |                 |         |
| above. A copy of this |   |   |   |   | I |   |                 |         |
| appointment form will |   |   |   |   | G |   |                 |         |
| be given to the       |   |   |   |   | N |   |                 |         |
| individual.           |   |   |   |   | A |   |                 |         |
|                       |   |   |   |   | T |   |                 |         |
|                       |   |   |   |   | U |   |                 |         |
|                       |   |   |   |   | R |   |                 |         |
|                       |   |   |   |   | E |   |                 |         |
|                       |   |   |   |   | O |   |                 |         |
|                       |   |   |   |   | F |   |                 |         |
|                       |   |   |   |   | P |   |                 |         |
|                       |   |   |   |   | R |   |                 |         |
|                       |   |   |   |   | O |   |                 |         |
|                       |   |   |   |   | G |   |                 |         |
|                       |   |   |   |   | R |   |                 |         |
|                       |   |   |   |   | A |   |                 |         |
|                       |   |   |   |   | M |   |                 |         |
|                       |   |   |   |   | D |   |                 |         |
|                       |   |   |   |   | I |   |                 |         |
|                       |   |   |   |   | R |   |                 |         |
|                       |   |   |   |   | E |   |                 |         |
|                       |   |   |   |   | C |   |                 |         |
|                       |   |   |   |   | T |   |                 |         |
|                       |   |   |   |   | O |   |                 |         |
|                       |   |   |   |   | R |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| \(c\) TYPED NAME OF   |   |   |   |   |   |   |                 |         |
| PROGRAM DIRECTOR      |   |   |   |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
| \(d\) INSTITUTION'S   |   |   |   |   |   |   |                 |         |
| NAME, ADDRESS, AND    |   |   |   |   |   |   |                 |         |
| PHONE NO.             |   |   |   |   |   |   |                 |         |
|                       |   |   |   |   |   |   |                 |         |
| > (Street, city,      |   |   |   |   |   |   |                 |         |
| > state, zip code)    |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+
|                       |   |   |   |   |   |   |                 |         |
+-----------------------+---+---+---+---+---+---+-----------------+---------+

PHS 2271 (Rev. 11/07) Page 2 of 2

## Privacy Act Statement {#privacy-act-statement .privacyact-title}

The PHS maintains application and grant records as part of a system of
records as defined by the Privacy Act: 09-25-0112, Grants and
Cooperative Agreements: Research, Research Training, Fellowship, and
Construction Applications and Related Awards. The Privacy Act of 1974 (5
USC 522a) allows disclosures for "routine uses" and permissible
disclosures.

Some routine uses may be:

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 the 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;
>
> \(2\) 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).

## Specialty Boards {#specialty-boards .privacyact-title}

If applicable, select a single specialty or subspecialty to complete
item 17. If more than one applies, select the one most closely related
to the field of career development or research training for this
appointment.

Allergy and Immunology

Allergy and Immunology

Anesthesiology

Anesthesiology (General)

Critical Care Medicine

Hospice and Palliative Medicine

Pain Medicine

Colon and Rectal Surgery

Colon and Rectal Surgery

Dermatology

Dermatology (General)

Clinical and Laboratory Dermatological

Dermatopathology

Immunology

Pediatric Dermatology

Dental

Dental Public Health

Endodontics

Oral and Maxillofacial Pathology

Oral and Maxillofacial Radiology

Oral and Maxillofacial Surgery

Orthodontics and Dentofacial Orthopedics

Pediatric Dentistry

Periodontics

Prosthodontics

Emergency Medicine

Emergency Medicine (General)

Hospice and Palliative Medicine

Medical Toxicology

Pediatric Emergency Medicine

Sports Medicine

Undersea and Hyperbaric Medicine

Family Medicine

Family Medicine (General)

Adolescent Medicine

Geriatric Medicine

Hospice and Palliative Medicine

Sleep Medicine

Sports Medicine

Internal Medicine

Internal Medicine (General)

Adolescent Medicine

Cardiovascular Disease

Clinical Cardiac Electrophysiology

Critical Care Medicine

Endocrinology, Diabetes and Metabolism

Gastroenterology

Geriatric Medicine

Hematology

Hospice and Palliative Medicine

Infectious Disease

Interventional Cardiology

Medical Oncology

Nephrology

Pulmonary Disease

Rheumatology

Sleep Medicine

Sports Medicine

Transplant Hepatology

Medical Genetics

Clinical Biochemical Genetics

Clinical Cytogenetics

Clinical Genetics (M.D.)

Clinical Molecular Genetics

Molecular Genetic Pathology

Ph.D. Medical Genetics

Neurological Surgery

Neurological Surgery

Nuclear Medicine

Nuclear Medicine

Nursing

Acute Care Nurse Practitioner

Adult Nurse Practitioner

Adult Psychiatric and Mental Health Nurse Practitioner

Advanced Clinical Diabetes Management, Clinical Nurse Specialist

Advanced Clinical Diabetes Management, Nurse Practitioner

Gerontological Nurse Practitioner

Clinical Nurse Specialist in Adult Health (formerly Medical-Surgical)
Nursing

Clinical Nurse Specialist in Adult Psychiatric and Mental Health Nursing

Clinical Nurse Specialist in Child and Adolescent Psychiatric and Mental
Health Nursing

Clinical Nurse Specialist in Home Health Nursing

Clinical Nurse Specialist in Pediatric Nursing

Clinical Nurse Specialist in Public/Community Health Nursing

Clinical Nurse Specialist in Gerontological Nursing

Family Nurse Practitioner

Family Psychiatric and Mental Health Nurse Practitioner

Pediatric Nurse Practitioner

School Nurse Practitioner

Obstetrics and Gynecology

Obstetrics and Gynecology (General)

Critical Care Medicine

Gynecologic Oncology

Hospice and Palliative Medicine

Maternal and Fetal Medicine

Reproductive Endocrinology/Infertility

Ophthalmology

Ophthalmology

Orthopaedic Surgery

Orthopaedic Surgery (General)

Orthopaedic Sports Medicine

Surgery of the Hand

Otolaryngology

Otolaryngology (General)

Neurotology

Pediatric Otolaryngology

Plastic Surgery Within the Head and Neck

Sleep Medicine

Pathology

Anatomic Pathology and Clinical Pathology (General)

Pathology-Anatomic (General)

Pathology-Clinical (General)

Blood Banking/Transfusion Medicine

Chemical Pathology

Cytopathology

Dermatopathology

Forensic Pathology

Hematology

Medical Microbiology

Molecular Genetic Pathology

Neuropathology

Pediatric Pathology

Pediatrics

Pediatrics (General)

Adolescent Medicine

Child Abuse Pediatrics

Developmental-Behavioral Pediatrics

Hospice and Palliative Medicine

Medical Toxicology

Neonatal-Perinatal Medicine

Neurodevelopmental Disabilities

Pediatric Cardiology

Pediatric Critical Care Medicine

Pediatric Emergency Medicine

Pediatric Endocrinology

Pediatric Gastroenterology

Pediatric Hematology-Oncology

Pediatric Infectious Diseases

Pediatric Nephrology

Pediatric Pulmonology

Pediatric Rheumatology

Pediatric Transplant Hepatology

Sleep Medicine

Sports Medicine

Physical Medicine and Rehabilitation

Physical Medicine and Rehabilitation (General)

Hospice and Palliative Medicine

Pain Medicine

Neuromuscular Medicine

Pediatric Rehabilitation Medicine

Spinal Cord Injury Medicine

Sports Medicine

Plastic Surgery

Plastic Surgery (General)

Plastic Surgery Within the Head and Neck

Surgery of the Hand

Preventive Medicine

Aerospace Medicine

Medical Toxicology

Occupational Medicine

Public Health and General Preventive Medicine

Undersea and Hyperbaric Medicine

Psychiatry and Neurology

Neurology (General)

Psychiatry (General)

Addiction Psychiatry

Child and Adolescent Psychiatry

Clinical Neurophysiology

Forensic Psychiatry

Geriatric Psychiatry

Hospice and Palliative Medicine

Neurodevelopmental Disabilities

Neurology with Special Qualifications in Child Neurology

Neuromuscular Medicine

Pain Medicine

Psychosomatic Medicine

Sleep Medicine

Vascular Neurology

Radiology

Diagnostic Radiology

Hospice and Palliative Medicine

Neuroradiology

Nuclear Radiology

Pediatric Radiology

Radiation Oncology

Radiologic Physics

Vascular and Interventional Radiology

Surgery

Surgery (General)

Hospice and Palliative Medicine

Pediatric Surgery

Surgery of the Hand

Surgical Critical Care

Vascular Surgery

Thoracic Surgery

Thoracic Surgery

Urology

Urology (General)

Pediatric Urology