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Health and Human Services (HHS) | |||
|---|---|---|---|
| Form Number | Title | Revision Date | Form Link |
| HHS-520 | Request for Approval of Outside Activity | 01/06 |  |
| HHS-521 | Annual Report of Outside Activity | 01/06 | |
| HHS-568 | Procedures for Submission of Final Invention Statement | 06/15 | |
| HHS-691 | Request for Title 38 Physician, Dentist and Podiatrist Pay (PDP) | 01/21 | |
| HHS-697* | Foreign Activities Questionnaire* | 10/20 | |
| HHS-719 | Request for Copy of the Record(s) in the Case File | 09/05 | |
| HHS-720 | Request for Copy of Record(s): Third –Party With the Individual Appellant's Consent | 08/05 | |
| HHS-721 | Individual Appellant's Consent to Third-Party for Copies for the Individual Appellant's Record(s) | 08/05 | |
| HHS-724 | Request to Correct, Amend, or Delete a Record (s) | 08/05 | |
| HHS-733 | Identity Verification | 08/05 | |
| HHS-734 | Payment Information Report | 09/05 | |
| HHS-990-1 (NTEU) | HHS Workplace Flexibilities Agreement (NTEU Employees Only) | 05/23 | |
HHS-990-2 | HHS Telework Agreement Form (New Form) | 03/25 |
|
Public Health Service (PHS) | |||
| N/A | Commissioned Corps of the U.S. Public Health Service – General Instructions for Completing Medical Examination Forms DD-2807-1 "Report of Medical History" and DD-2808 "Report of Medical Examination" | 07/18 | |
| N/A | PHS Request for Basic Training Contract Memo | 01/23 | |
| N/A | PHS Sample Memorandum To Request Payment of A Uniform Allowance | 09/20 | |
| N/A | PHS Service Award, Campaign Medal, and Training Ribbons Nomination Record | 01/23 | |
| N/A | PHS LTT Forms Checklist PHS Training Purposes and Objectives | 01/23 01/23 |
|
| PHS-398 | Public Health Service – Includes Research Career Awards and Institutional National Research Service Awards | 03/20 | |
| PHS-416-1 | Application for an Individual National Research Service Award Fellowship Instructions | 01/21 | |
| PHS-416-5 | Research Fellowship Activation Notice | 04/20 | |
| PHS-416-7 | Termination Notice NRSA | 06/15 | |
| PHS-416-9 | Application for PHS Individual National Research Service Continuation Award Instructions | 08/12 | |
| PHS-488 | Claim for Temporary Lodging Allowance | 09/20 | |
| PHS-838 | Commissioned Officers Effectiveness Report | 08/15 | |
| PHS-1122-1 | Application for Training for PHS Commissioned Personnel (Privacy Act) (Also print the cover memo) | 01/23 | |
| PHS-1345 | Request and Authority for Leave of Absence (Commissioned Officers) | 09/05 | |
PHS-1373 | Separation of Commissioned Officer | 05/24 | |
| PHS-1637-1 | Public Health Service - Commissioned Officer's Request for Dependency Determination | 11/20 | |
| PHS-1662 | Request for Personnel Action - Commissioned Officer | 10/04 | |
| PHS-1881-1 | Basic Training Contract | 01/23 | |
| PHS-1881-2 | Order Pursuant to Basic Training Contract | 01/23 | |
| PHS-2271 | Information and Instructions for Completing Statement of Appointment (Form PHS-2271) (Includes Application) | 04/24 | |
| PHS-2590 | Application for Continuation of a PHS Grant | 03/16 | |
| PHS-2874 | Notice of Arrival | 04/24 | |
| PHS-2977 | Quarters Allowance Certificate | 05/90 | |
| PHS-2988 | Voucher for Reimbursement for Travel Dependents of PHS COs | 03/24 | |
| PHS-3734 | Official Statement Relinquishing Interests and Rights in a Public Health Service Research Grant | 06/15 | |
| PHS-4013-1 | Application for Shipments of Household Goods (Commissioned Officers) | 11/24 | |
| PHS-4392 | Billet Description | 02/24 | |
| PHS-5141-2 | Appointment Affidavit Regular Corps | 12/24 | |
| PHS-6031 | National Research Service Award | 08/18 | |
| PHS-6031-1 | Annual National Research Service Award | 06/15 | |
| PHS-6051 | Merit Promotion Program Certificate for Eligibles | 01/90 | |
| PHS-6051-1 | AHCPR Certificates for Eligibles | 05/90 | |
| PHS-6059 | Request for Overseas Allowances | 09/20 | |
| PHS-6106 | Agreement - To Receive an Allowance under the Federal Physicians Comparability Allowance Program | 09/88 | |
| PHS-6173 | Application for Allotment of Pay (NON-GI BILL: use PHS-7039 for GI BILL) | 09/20 | |
| PHS-6189-1 | Retention Bonus (RB) Agreement Request | 12/18 | |
| PHS-6231 | Certification for Intermittent Tours of Duty | 09/20 | |
| PHS-6310-1 | Incentive Pay (IP) Agreement | 12/18 | |
| PHS-6315 | Assurance of Compliance by Sub-Award Recipients | 02/24 | |
| PHS-6342-1 | Unit Honor Award Nomination Record - Part 1 | 12/24 | |
| PHS-6342-2 | Individual Honor Award Nomination Record - Part 1 | 12/24 | |
| PHS-6349 | Annual Report on Possible Research Misconduct | 10/24 | |
| PHS-6353 | PHS Commissioned Officer State Tax Withholding Allowance Certificate | 09/20 | |
| PHS-6355 | Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service | 05/17 | |
| PHS-6363 | Request to Establish/Change Mailing Address | 11/20 | |
| PHS-6364 | PHS Employee Invention Report | 01/93 | |
| PHS-6367 | Active-Duty Certification (Short Tours of Less Than 30 Days) | 09/20 | |
| PHS-6373 | Extramural Training Agreement | 02/24 | |
| PHS-6374 | Intramural Training Agreement | 02/24 | |
| PHS-6380 | Request for Uniformed Services Medical Records | 01/05 | |
| PHS-7015-1 | Board Certification Incentive Pay (BCIP) Agreement Request | 02/25 | |
| PHS-7033 | Special Pay Contract - Accession Bonus | 11/18 | |
| PHS-7036 | Reimbursement Request Expenses for Adoption | 09/20 | |
| PHS-7044 | Annual Physical Fitness Test (APFT) Report | 03/26 | |
| PHS-7044-1 | Verified Weight Report | 11/24 | |
| PHS-7045 | Temporary Lodging Expense (TLE) Computation Worksheet | 09/16 | |
| PHS-7062 | Extramural Training Agreement (Scholarships, Grants, Fellowships) | 01/23 | |
| PHS-7064 | Training Agreement for Officers Assigned as Students to School of Medicine Form | 01/23 | |
| PHS-7082-2 | Post-9/11 GI Bill Educational Benefits Transferability Commitment and Statement of Understanding | 04/20 | |
| PHS-7083 | Behavioral Health Survey | 02/24 | |
PHS-7088 | Practice Hours Waiver Request | 03/24 |
|
PHS-7089 | Special Duty Pay (SDP) Agreement | 01/25 |
|
PHS-7090 | Opt Out Request | 01/25 |
|
Substance Abuse and Mental Health Services Administration (SAMHSA) | |||
| SMA-162 | Application for Certification to Use Opioid Drugs in a Treatment Center | 02/18 | |
Indian Health Service | |||
| N/A | IHS Child Care & Indian Child Care Worker Positions Form | 08/23 | |
| N/A | IHS Individual Overtime, Compensatory Time and Credit Hours Request Form | 03/23 | |
| IHS-515* | Authorization for Administration of Anesthesia and for Performance of Operations or Other Procedures* | 11/94 | |
| IHS-810 | IHS Authorization for Release of Information | 05/24 | |
| IHS-912-1 | Request for Restriction(s) | 01/24 | |
| IHS-912-2 | Request for Revocation of Restriction(s) | 01/24 | |
| IHS-913 | Request for Accounting of Disclosures | 01/24 | |
| IHS-917 | Request for Correction/Amendment of Protected Health Information | 01/24 | |
| IHS-961* | IHS Agreement to Assign Claim Upon Request Form* | 11/21 | |
| IHS-963 | IHS Request for Confidential Communication by Alternative Means or Alternate Location | 01/24 | |
| IHS-969 | IHS Certificate of Records Destruction Form | 09/21 | |
| IHS-975 | Request for Ratification of Unauthorized Commitment (UAC) | 05/19 | |
| IHS-976 | Purchased/Referred Care Proof of Residency | 10/17 | |
| IHS-978 | Records Contact Designation | 08/21 | |
| IHS-982 | IHS Acknowledgement of Receipt of IHS Notice of Privacy Practices | 01/24 | |
The contents on this site noted with "*" are in the process of Section 508 review. If you need immediate assistance accessing the content, please submit a request to Cheryllyn Bachelor (PSC) at Cheryllyn.Bachelor@psc.hhs.gov. Content will be updated pending the outcome of the Section 508 review.