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).
PHS 416-7 (Rev. 9 /08) Privacy Act
