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Health and Human Services (HHS) |
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|---|---|---|---|
| Form Number |
Title
|
Revision Date
|
Form Link
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| HHS-520 | Request for Approval of Outside Activity |
01/06
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 |
| HHS-521 | Annual Report of Outside Activity |
01/06
|
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| HHS-568 | Procedures for Submission of Final Invention Statement |
06/15
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| HHS-691 | Request for Title 38 Physician, Dentist and Podiatrist Pay (PDP)* |
01/21
|
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| HHS-697* | Foreign Activities Questionnaire* |
10/20
|
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| HHS-719 | Request for Copy of the Record(s) in the Case File |
09/05
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| HHS-720 | Request for Copy of Record(s): Third –Party With the Individual Appellant's Consent |
08/05
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| HHS-721 | Individual Appellant's Consent to Third-Party for Copies for the Individual Appellant's Record(s) |
08/05
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| HHS-724 | Request to Correct, Amend, or Delete a Record (s) |
08/05
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| HHS-733 | Identity Verification |
08/05
|
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| HHS-734 | Payment Information Report |
09/05
|
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| HHS-990-1 | HHS Workplace Flexibilities Agreement |
01/23
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| HHS-990-1 (NTEU) | HHS Workplace Flexibilities Agreement (NTEU Employees Only) |
05/23
|
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|
Public Health Service (PHS) |
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| 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" |
11/16
|
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| N/A | PHS Request for Basic Training Contract Memo |
01/23
|
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| N/A | PHS Sample Memorandum To Request Payment of A Uniform Allowance |
09/20
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| N/A | PHS Service Award, Campaign Medal, and Training Ribbons Nomination Record |
01/23
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| N/A | PHS LTT Forms Checklist PHS Training Purposes and Objectives |
01/23
01/23 |
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| PHS-398 | Public Health Service – Includes Research Career Awards and Institutional National Research Service Awards |
03/20
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| PHS-416-1 | Application for an Individual National Research Service Award Fellowship Instructions |
01/21
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| PHS-416-5 | Research Fellowship Activation Notice |
04/20
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| PHS-416-7 | Termination Notice NRSA |
06/15
|
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| PHS-416-9 | Application for PHS Individual National Research Service Continuation Award Instructions |
08/12
|
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| PHS-488 | Claim for Temporary Lodging Allowance |
09/20
|
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| PHS-838 | Commissioned Officers Effectiveness Report |
08/15
|
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| PHS-1122 | Application for Training for PHS Commissioned Personnel (Privacy Act) (Also print the cover memo) [PDF] |
01/23
|
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| PHS-1345 | Request and Authority for Leave of Absence (Commissioned Officers) |
09/05
|
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| PHS-1637-1 | Public Health Service - Commissioned Officer's Request for Dependency Determination |
11/20
|
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| PHS-1662 | Request for Personnel Action - Commissioned Officer |
10/04
|
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| PHS-1881-1 | Basic Training Contract |
01/23
|
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| PHS-1881-2 | Order Pursuant to Basic Training Contract |
01/23
|
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| PHS-2271 | Information and Instructions for Completing Statement of Appointment (Form PHS-2271) (Includes Application) |
06/15
|
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| PHS-2590 | Application for Continuation of a PHS Grant |
03/16
|
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| PHS-2874 | Notice of Arrival |
09/20
|
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| PHS-2988 | Voucher for Reimbursement for Travel Dependents of PHS COs |
11/16
|
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| PHS-3734 | Official Statement Relinquishing Interests and Rights in a Public Health Service Research Grant |
06/15
|
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| PHS-4013-1 | Application for Shipments of Household Goods (Commissioned Officers) |
08/16
|
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| PHS-4392 | Billet Description |
04/06
|
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| PHS-5141-2 | Appointment Affidavit Regular Corps |
08/16
|
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| PHS-6031 | National Research Service Award |
08/18
|
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| PHS-6031-1 | Annual National Research Service Award |
06/15
|
|
| PHS-6051 | Merit Promotion Program Certificate for Eligibles |
01/90
|
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| PHS-6051-1 | AHCPR Certificates for Eligibles |
05/90
|
|
| PHS-6059 | Request for Overseas Allowances |
09/20
|
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| PHS-6106 | Agreement - To Receive an Allowance under the Federal Physicians Comparability Allowance Program |
09/88
|
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| PHS-6173 | Application for Allotment of Pay (NON-GI BILL: use PHS-7039 for GI BILL) |
09/20
|
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| PHS-6189-1 | Retention Bonus (RB) Agreement Request |
12/18
|
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| PHS-6231 | Certification for Intermittent Tours of Duty |
09/20
|
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| PHS-6300-1 | Medical Special Pay (MSP) Contract Request |
04/98
|
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| PHS-6310-1 | Incentive Pay (IP) Agreement |
12/18
|
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| PHS-6315 | Assurance of Compliance by Sub-Award Recipients |
08/23
|
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| PHS-6342-2 | Individual Honor Award Nomination Record - Part 1 |
10/16
|
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| PHS-6349 | Annual Report on Possible Research Misconduct |
08/23
|
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| PHS-6353 | PHS Commissioned Officer State Tax Withholding Allowance Certificate |
09/20
|
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| PHS-6353-1 | Request for Voluntary State Income Tax Withholding from Retired Pay |
03/05
|
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| PHS-6355 | Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service |
05/17
|
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| PHS-6363 | Request to Establish/Change Mailing Address |
11/20
|
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| PHS-6364 | PHS Employee Invention Report |
01/93
|
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| PHS-6367 | Active-Duty Certification (Short Tours of Less Than 30 Days) |
09/20
|
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| PHS-6373 | Extramural Training Agreement |
01/23
|
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| PHS-6374 | Intramural Training Agreement |
01/23
|
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| PHS-6379 | Supplemental Medical History Record Required of Applicants to the Public Health Service Commissioned Corps |
05/17
|
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| PHS-7015 | Engineering and Scientific Career Continuation Pay (ESCCP) Contract Request |
09/01
|
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| PHS-7015-1 | Board Certification Incentive Pay (BCIP) Agreement Request |
12/18
|
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| PHS-7033 | Special Pay Contract - Accession Bonus |
12/18
|
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| PHS-7036 | Reimbursement Request Expenses for Adoption |
09/20
|
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| PHS-7044 | Commissioned Corps Annual Physical Fitness Test (APFT) Readiness Standards Report |
07/19
|
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| PHS-7044-1 | Verified Weight Report |
09/18
|
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| PHS-7045 | Temporary Lodging Expense (TLE) Computation Worksheet |
09/16
|
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| PHS-7062 | Extramural Training Agreement (Scholarships, Grants, Fellowships) |
01/23
|
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| PHS-7064 | Training Agreement for Officers Assigned as Students to School of Medicine Also print the cover memo [PDF] |
02/23
|
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| PHS-7082-2 | Post-9/11 GI Bill Educational Benefits Transferability Commitment and Statement of Understanding* |
06/19
|
|
| PHS-7083 | Behavioral Health Survey |
01/20
|
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| PHS-7085 | Position/Billet Addendum |
12/20
|
|
|
Substance Abuse and Mental Health Services Administration (SAMHSA) |
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| SMA-162 | Application for Certification to Use Opioid Drugs in a Treatment Center |
02/18
|
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| SMA-167 | Notification of Intent to Use Opioid Drugs for Maintenance and Treatment |
00/00
|
|
| SMA-172 | SAMHSA Application for Peer Grant Review |
Exp 09/17
|
|
|
Indian Health Service |
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| 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 |
11/23
|
|
| IHS-912-1 | Request for Restriction(s) |
11/23
|
|
| IHS-912-2 | Request for Revocation of Restriction(s) |
11/23
|
|
| IHS-913 | Request for Accounting of Disclosures |
11/23
|
|
| IHS-917 | Request for Correction/Amendment of Protected Health Information |
11/23
|
|
| IHS-961* | IHS Agreement to Assign Claim Upon Request Form |
11/21
|
|
| IHS-963 | Request for Confidential Communication by Alternative Means or Alternate Location |
04/09
|
|
| 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
|
|
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.