Content created by Program Support Center (PSC)
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-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 | HHS Workplace Flexibilities Agreement | 04/24 | |
| HHS-990-1 (NTEU) | HHS Workplace Flexibilities Agreement (NTEU Employees Only) | 05/23 | |
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) | 08/16 | |
| PHS-4392 | Billet Description | 02/24 | |
| PHS-5141-2 | Appointment Affidavit Regular Corps | 08/16 | |
| 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-6342-2 | Individual Honor Award Nomination Record - Part 1 | 10/16 | |
| PHS-6349 | Annual Report on Possible Research Misconduct | 02/24 | |
| 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-6379 | Supplemental Medical History Record Required of Applicants to the Public Health Service Commissioned Corps | 05/17 | |
| PHS-6380 | Request for Uniformed Services Medical Records | 01/05 | |
| PHS-7015-1 | Board Certification Incentive Pay (BCIP) Agreement Request | 12/18 | |
| PHS-7033 | Special Pay Contract - Accession Bonus | 11/18 | |
| PHS-7036 | Reimbursement Request Expenses for Adoption | 09/20 | |
| PHS-7044 | Commissioned Corps Annual Physical Fitness Test (APFT) Readiness Standards Report | 07/19 | |
| PHS-7044-1 | Verified Weight Report | 09/18 | |
| 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 | |
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.