National Institutes of Health

National Institutes of Health Ethics Program

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Ethics Forms and Deadlines

The following ethics forms are provided to assist employees to obtain advance approval where required, and resolve real and apparent conflicts of interest.  Forms are provided in various formats, as indicated below. Some forms use table format with locked cells to allow the user to tab between the blank cells where information must be entered, skipping over the text of the form (e.g., NIH-2657). Other forms are in memo or straight text format and the user fills in the requested information. Please check your spacing before printing to maintain the appropriate pagination and format.

These documents can be viewed on-line if you have the appropriate software (Acrobat Reader, Word, or WordPerfect, depending on which format you choose) on your computer or they can be saved to your computer. A description of each form is provided below. Click on the highlighted text to initiate the download/save function in your browser (i.e., Netscape or Internet Explorer).  If you have questions regarding Acrobat, please seek assistance from your computer support group.

NOTE:  Word Versions: Click on the Word link; this opens both Word and the document.  WordPerfect files must be saved before they will open. Click on the WP link and choose "Save" in the pop-up window.  If you have not changed your default options, a second pop-up window will verify it is saved and give you the option to "Open" the file.  Otherwise, remember where the file is saved on your computer. ALL submissions must use the current version of the form.

Deadlines for Ethics Actions Requiring Review by the NIH Ethics Office (NEO) and 
Determination by the NIH Deputy Ethics Counselor (DEC)
Coverage: 
 *  Outside Activities under NEAC jurisdiction
 *  Awards under NEAC jurisdiction or requiring pre-screening		 Coverage: 
 *  Official Duty Activities
 *  Widely Attended Gatherings
 * Awards (non-NEAC review)
 *  Honorary Degrees

DEADLINE FOR SUBMISSION TO NEO:  Minimum of 6 weeks in advance of activity or associated travel. If  less than 6 weeks prior to proposed start date, it must be received in NEO within 5 business days of the employee's receipt of the invitation.

NEAC Meeting Dates

 DEADLINE FOR SUBMISSION TO NEO:  Minimum of 4 weeks in advance of activity or associated travel. If  less than 4 weeks prior to proposed start date, it must be received in NEO within 5 business days of the employee's receipt of the invitation.


 Any actions received by NEO within 5 business days of the activity must have all of the following requirements:
 *  Must have IC Director approval (or designee in his/her absence) prior to submission to NEO;
 *  Must be determined to be a critical and essential activity; AND
 *  Must be accompanied by a last minute invitation or notification.

The NEO will not guarantee that any actions received later than the above deadlines can be processed.  Unless advance approval is obtained, the employee may not conduct the activity.

For additional information, contact your IC's Deputy Ethics Counselor or Ethics Coordinator.

Outside Activities    
The following forms are used as indicated to request approval to engage in an outside activity (personal, outside work).
1.

This form is used within the Department of Health and Human Services (DHHS) to request approval of proposed Outside Activities (activities which are totally outside regular official duties, and with outside organizations). Required for all Outside Activities.

NIH Enterprise Ethics System (NEES) (electronic submission)

HHS-520 (1/06), Request for Approval of Outside Activity  (Acrobat Format, fillable*) - Optional until 4/15/08

2. NIH-2657 (1/04), Supplemental Information to the HHS-520 
This NIH form is used to provide additional information for certain Outside Activities.  Required for consulting for industry (complete Part B), legal consulting/testimony (complete Part C), and Professional Practice for physicians, nurses, and allied health care professionals (Complete Part D).
Acrobat Format* Word format
3. NIH Policy Regarding Supervisory Review of Outside Activities:  (Acrobat format*)
This memorandum, dated February 16, 2004, from the NIH Deputy Director/NIH Deputy Ethics Counselor to all supervisors details supervisory and management responsibilities for reviewing Requests for Approval of Outside Activity, HHS 520.
4. HHS-521 (1/06) Annual Report of Outside Activity:  (Acrobat format, fillable*)
This form is used to submit a report of all your Outside Activities during the previous calendar year; due February 28th each year. You will be notified when it is time to complete and submit the Annual Report. The 1/06 version must be used; all previous versions are obsolete.
  Detailed Instructions for Completing and Reviewing the HHS-521 (Acrobat format*)
5. HHS 520 Request for Approval of Outside Activity: For use ONLY for Outside Professional Practice for Clinical Fellows
 

 

Activities Involving Foreign Entities
HHS-697, Foreign Activities Questionnaire (4/02)  (Acrobat Format, fillable*)
Use this form for activities involving a foreign entity or organization.
 

Official Duty Activities 
Memo to Request Approval of Official Duty Activity
This memo is used to request approval of certain activities involving outside organizations which are outside your regular official duties but will be performed as part of your official duty. Three samples are provided, as described below.
1.
Requests from employees to their IC Deputy Ethics Counselor or Supervisor (Rev 9/07)
2. Requests from NIH Senior Employees (Top 5), DECs, and OD staff to the NIH DEC (Rev 1/28/06)
3. Blanket Official Duty Request Memo (7/07) See the June 1, 2007, memo from NIH DEC to IC Directors.
Copyright and Publication Issues: An employee working in an official capacity is working on behalf of the NIH, not in a personal capacity, and without appropriate authority, may not sign legal documents which bind the NIH. Employees may NOT sign any forms from publishers or other outside entities, but must use the approved NIH forms and follow the NIH Procedure for Complying with the NIH Public Access Policy, which was distributed by OIR on May 15, 2008. The procedure and public access policy documents are maintained on the NIH Office of Intramural Research Source Book web site. Use the above link for access to the various documents.
Gift Exceptions (Permission to Accept Certain Gifts)
1. Form NIH-2854 Request for Approval to Accept Gifts Associated with an Award from an Outside Organization
Use this form to obtain advance approval to accept the gifts associated with an award from an outside organizations. All employees must obtain advance approval. Use only this version (5/08).
2. HHS Honorary Degree Review and Approval Form (April 1999)  
Use this form to obtain advance approval to accept an honorary degree and set the period of disqualification for the employee receiving the degree. Your Deputy Ethics Counselor will determine the permissibility of an honorary degree.
Acrobat Format*
 Word 97 format WordPerfect format
3. Review/Approval Form for Widely Attended Gatherings (WAG)
Use this form to request permission to accept free attendance at a Widely Attended Gathering, e.g., receptions or dinners, where you are not presenting or participating in another way other than as an attendee.
Word Format
 WordPerfect format
 
Protocol COI Statement (3/08)
Use this form to request conflict of interest clearance by the IC Deputy Ethics Counselor (DEC) for all investigators. Includes instructions for using the form and clearing the protocol.
 

Mechanisms to Manage Real and Apparent Conflicts of Interest
1. Waiver of Actual Conflict of Interest [18 USC Section 208(b)(1)]: 
This is the standard waiver format used to resolve an actual conflict of interest under 18 USC 208(b)(1), the statute governing such issues.
Word format WordPerfect format
2. Waiver of Actual Conflict for Officers or Directors [18 USC Section 208(b)(1)]: 
This is the waiver format used to resolve conflict of interest issues for employees serving as an officer of director of an outside organization and such service is done as part of their official duties.
Word format WordPerfect format
3. Authorization to Participate [5 CFR 2635 Section 502] (Revised 3/06): 
This is the standard authorization format used to resolve appearances of conflicts of interest (vs. actual conflicts which use a waiver, above).
Word format WordPerfect format
4. Recusal/Disqualification: 
This is the standard format used to identify and obtain approval to be disqualified from certain official duties with outside organizations with which you have another ongoing relationship, such as an outside activity or financial interest (i.e., stock), or with which you may be seeking employment.
Employees other than IC Directors: Word format WordPerfect format
IC Directors:
 Word format WordPerfect format
 
Financial Disclosure Forms:
Follow the links below to obtain details, forms and resources.
1. Public Financial Disclosure Reports (SF-278) for senior level (SES, ST, SL, O-7 and above, and others in identified positions)
2. Confidential Financial Disclosure Reports (OGE-450) for employees in designated positions with relevant responsibilities.
3. Confidential Report of  Financial Interests in Substantially Affected Organizations for Employees of the NIH (HHS-717-1) (5/07) Required of all public and confidential filers, and all clinical investigators. Use this form to submit the initial report of your financial interests in SAOs and when you acquire a financial interest in an SAO (i.e., purchase, gift).
 

Referral of Employees for Non-Compliance with Ethics Requirements:
1.

Form NIH-2850, Referral for Non-Compliance with Ethics Requirements (5/08) (pdf)*
2.

Procedure for Managing Employee Non_Compliance with Ethics Requirements (Using Form NIH-2850) (pdf)
3.
4.
 
Semiannual Report of Payments Accepted from a Non-Federal Source
SF 326 - Main form
 SF 326A - Continuation Sheet  (Acrobat Format*)

*NOTE: You must have the free Acrobat Reader software on your computer to review and print these forms or documents in pdf format. If you do not have the Reader software, you may download it below. Note that after you download the file, you must also install it. Please carefully read the instructions on the download screen and complete both steps.

Download Adobe Acrobat Reader

For assistance with forms, please contact your IC's Deputy Ethics Counselor or Ethics Coordinator.

Updated: 11/5/08