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Public Use Forms by Number

We are committed to ensuring that all HHS forms on this Web site are fully accessible to individuals with disabilities in accordance with Section 508 of the Rehabilitation Act. If you have any difficulty viewing any page with adaptive technology, please contact the webmaster for this site, or the HHS Forms Coordinator.

Documents on the HHS Web sites are available in PDF format. These forms are accessible to users using Microsoft Active Accessibility (MSAA), JAWs for Windows screen reading software as well as Dragon Naturally Speaking Voice Recognition Software. Adobe provides their Acrobat Reader software as a free download.

Health and Human Services (HHS)

Form Number
Title
Revision Date
Form Link
HHS-520Request for Approval of Outside Activity
01/06
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HHS-521Annual Report of Outside Activity
01/06
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HHS-568Procedures for Submission of Final Invention Statement
06/15
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HHS-691Request 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-719Request for Copy of the Record(s) in the Case File
09/05
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HHS-720Request for Copy of Record(s): Third –Party With the Individual Appellant's Consent
08/05
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HHS-721Individual Appellant's Consent to Third-Party for Copies for the Individual Appellant's Record(s)
08/05
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HHS-724Request to Correct, Amend, or Delete a Record (s)
08/05
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HHS-733Identity Verification
08/05
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HHS-734Payment Information Report
09/05
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HHS-990-1 (NTEU)HHS Workplace Flexibilities Agreement (NTEU Employees Only)
05/23
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HHS-990-2

HHS Telework Agreement Form (New Form)

03/25

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Public Health Service (PHS)

  
N/ACommissioned 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
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N/APHS Request for Basic Training Contract Memo
01/23
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N/APHS Sample Memorandum To Request Payment of A Uniform Allowance
09/20
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N/APHS Service Award, Campaign Medal, and Training Ribbons Nomination Record
01/23
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N/APHS LTT Forms Checklist

PHS Training Purposes and Objectives
01/23

01/23
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PHS-398Public Health Service – Includes Research Career Awards and Institutional National Research Service Awards
03/20
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PHS-416-1Application for an Individual National Research Service Award Fellowship
Instructions
01/21
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PHS-416-5Research Fellowship Activation Notice
04/20
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PHS-416-7Termination Notice NRSA
06/15
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PHS-416-9Application for PHS Individual National Research Service Continuation Award
Instructions
08/12
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PHS-488Claim for Temporary Lodging Allowance
09/20
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PHS-838Commissioned Officers Effectiveness Report
08/15
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PHS-1122-1Application for Training for PHS Commissioned Personnel (Privacy Act)
(Also print the cover memo)
01/23
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PHS-1345Request and Authority for Leave of Absence (Commissioned Officers)
09/05
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PHS-1373

Separation of Commissioned Officer

05/24

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PHS-1637-1Public Health Service - Commissioned Officer's Request for Dependency Determination
11/20
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PHS-1662Request for Personnel Action - Commissioned Officer
10/04
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PHS-1881-1Basic Training Contract
01/23
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PHS-1881-2Order Pursuant to Basic Training Contract
01/23
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PHS-2271Information and Instructions for Completing Statement of Appointment (Form PHS-2271) (Includes Application)
04/24
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PHS-2590Application for Continuation of a PHS Grant
03/16
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PHS-2874Notice of Arrival
04/24
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PHS-2977Quarters Allowance Certificate
05/90
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PHS-2988Voucher for Reimbursement for Travel Dependents of PHS COs
03/24
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PHS-3734Official Statement Relinquishing Interests and Rights in a Public Health Service Research Grant
06/15
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PHS-4013-1Application for Shipments of Household Goods (Commissioned Officers) 
11/24
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PHS-4392Billet Description
02/24
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PHS-5141-2Appointment Affidavit Regular Corps
12/24
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PHS-6031National Research Service Award
08/18
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PHS-6031-1Annual National Research Service Award
06/15
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PHS-6051Merit Promotion Program Certificate for Eligibles
01/90
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PHS-6051-1AHCPR Certificates for Eligibles
05/90
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PHS-6059Request for Overseas Allowances
09/20
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PHS-6106Agreement - To Receive an Allowance under the Federal Physicians Comparability Allowance Program
09/88
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PHS-6173Application for Allotment of Pay (NON-GI BILL: use PHS-7039 for GI BILL)
09/20
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PHS-6189-1Retention Bonus (RB) Agreement Request
12/18
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PHS-6231Certification for Intermittent Tours of Duty
09/20
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PHS-6310-1Incentive Pay (IP) Agreement
12/18
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PHS-6315Assurance of Compliance by Sub-Award Recipients
02/24
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PHS-6342-1Unit Honor Award Nomination Record - Part 1
12/24
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PHS-6342-2Individual Honor Award Nomination Record - Part 1
12/24
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PHS-6349Annual Report on Possible Research Misconduct
10/24
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PHS-6353PHS Commissioned Officer State Tax Withholding Allowance Certificate
09/20
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PHS-6355Report of Dental Examination of Applicants to the Commissioned Corps of the Public Health Service
05/17
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PHS-6363Request to Establish/Change Mailing Address
11/20
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PHS-6364PHS Employee Invention Report
01/93
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PHS-6367Active-Duty Certification (Short Tours of Less Than 30 Days)
09/20
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PHS-6373Extramural Training Agreement
02/24
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PHS-6374Intramural Training Agreement
02/24
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PHS-6380Request for Uniformed Services Medical Records
01/05
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PHS-7015-1Board Certification Incentive Pay (BCIP) Agreement Request
02/25
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PHS-7033Special Pay Contract - Accession Bonus
11/18
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PHS-7036Reimbursement Request Expenses for Adoption
09/20
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PHS-7044Annual Physical Fitness Test (APFT) Report
11/24
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PHS-7044-1Verified Weight Report
11/24
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PHS-7045Temporary Lodging Expense (TLE) Computation Worksheet
09/16
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PHS-7062Extramural Training Agreement (Scholarships, Grants, Fellowships)
01/23
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PHS-7064Training Agreement for Officers Assigned as Students to School of Medicine Form
01/23
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PHS-7082-2Post-9/11 GI Bill Educational Benefits Transferability Commitment and Statement of Understanding
04/20
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PHS-7083Behavioral Health Survey
02/24
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PHS-7088

Practice Hours Waiver Request

03/24

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PHS-7089

Special Duty Pay (SDP) Agreement

01/25

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PHS-7090

Opt Out Request

01/25

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Substance Abuse and Mental Health Services Administration (SAMHSA)

  
SMA-162Application for Certification to Use Opioid Drugs in a Treatment Center
02/18
Online
 

 

Indian Health Service

  
N/AIHS Child Care & Indian Child Care Worker Positions Form
08/23
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N/AIHS Individual Overtime, Compensatory Time and Credit Hours Request Form
03/23
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IHS-515*Authorization for Administration of Anesthesia and for Performance of Operations or Other Procedures*
11/94
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IHS-810IHS Authorization for Release of Information
05/24
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IHS-912-1Request for Restriction(s)
01/24
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IHS-912-2Request for Revocation of Restriction(s)
01/24
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IHS-913Request for Accounting of Disclosures
01/24
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IHS-917Request for Correction/Amendment of Protected Health Information
01/24
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IHS-961*IHS Agreement to Assign Claim Upon Request Form*
11/21
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IHS-963IHS Request for Confidential Communication by Alternative Means or Alternate Location
01/24
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IHS-969IHS Certificate of Records Destruction Form
09/21
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IHS-975Request for Ratification of Unauthorized Commitment (UAC)
05/19
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IHS-976Purchased/Referred Care Proof of Residency
10/17
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IHS-978Records Contact Designation
08/21
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IHS-982IHS Acknowledgement of Receipt of IHS Notice of Privacy Practices
01/24
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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.

Content created by Program Support Center (PSC)
Content last reviewed April 3, 2025
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