Form PHS-6349 RESEARCH INTEGRITY ASSURANCE AND ANNUAL REPORT ON POSSIB

This is a DESIGN PROOF ONLY. Any fields and/or checkboxes
are non-functional and for position only. Functional fields will be
inserted by technical staff once the form design is approved.
DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved
OMB No. 0937-0198; Expires: XX/XX/XXXX
See Statement of Burden on Page 3

Public Health Service

RESEARCH INTEGRITY ASSURANCE
AND ANNUAL REPORT ON
POSSIBLE RESEARCH MISCONDUCT

Period Covered by this Report
January X, XXXX to December 31, XXXX

INSTRUCTIONS
Institutions maintain their assurance with the Office of Research Integrity (ORI) by filing this form between January 1st and April 30th annually.
Institutions must submit policies and procedures that comply with the Public Health Service (PHS) Policies on Research Misconduct (42 CFR
Part 93) with this form; however, if an institution believes it qualifies as a small institution, it may complete and submit the Small Institution
Statement with this form instead of submitting policies and procedures. A research integrity assurance cannot be maintained by ORI without
either policies and procedures or the Small Institution Statement. For questions, contact ORI_Assurance@hhs.gov or call (240) 453-8400.
INSTITUTIONAL CERTIFYING OFFICIAL’S NAME
INSTITUTIONAL CERTIFYING OFFICIAL’S TITLE
NAME OF INSTITUTION
MAILING ADDRESS OF INSTITUTIONAL CERTIFYING OFFICIAL

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CITY STATE ZIP CODE

COUNTRY

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SECTION I. ASSURANCE OF COMPLIANCE

The Institutional Certifying Official must assure the following on behalf of the institution. The institution certifies that:
It will comply with its policies and procedures for addressing allegations of research misconduct.

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It will comply with all provisions of 42 CFR Part 93.

It has checked for an active assurance with ORI. Institutions seeking to establish an ORI assurance should complete the Research
Integrity Assurance Establishment form found at ori.hhs.gov. Institutions can check for active assurances in the Annual Report System
at ori.hhs.gov/arprm/Login.php.
CHOOSE ONE:

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It has established written policies and procedures for addressing allegations of research misconduct, in compliance with 42 CFR Part 93.
Please attach your institutional policies and procedures with this form.
OR
It qualifies as a small institution and has attached a Small Institution Statement with this form. The Small Institution Statement form can also
be downloaded from ori.hhs.gov/small-institution-statement.

SECTION II. TYPES OF MISCONDUCT ACTIVITY RELATED TO PHS APPLICATIONS AND AWARDS
A.

PLEASE CHECK THE BOX (to the left) if your institution has NOT received any allegations or conducted any assessments,
inquiries or investigations of allegations during the reporting period that (1) fall under the definition of research misconduct in 42 CFR
Part 93 and (2) involve receipt of or requests for PHS funding, then complete Section III. Otherwise, please complete Section II.

B. Please provide the requested information for each incident of alleged misconduct that involved a request for or receipt of PHS funds that
fell within the PHS definition of research misconduct. Please note that, in accordance with 42 CFR 93.310(b), institutions must notify ORI of
the decision to begin an investigation on or before commencement of the investigation.
PLEASE NOTE: For each incident of alleged research misconduct resulting in an assessment, inquiry, and/or investigation at your
institution (1) provide the ORI case number, if assigned; (2) check the type of activity (assessment, inquiry, and/or investigation -- may
include more than one activity type for each reported incident); and (3) check the type of misconduct involved with each activity (may
include more than one type of misconduct). Attach a separate sheet if additional space or clarification is required.

(continued on next page)

PHS-6349 (Rev. 08/25)

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PSC Publishing Services (301) 443-6740

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This is a DESIGN PROOF ONLY. Any fields and/or checkboxes
are non-functional and for position only. Functional fields will be
inserted by technical staff once the form design is approved.
SECTION II.B (CONTINUED)
1. Activity continued into 2026:
Misconduct activity in
conjunction with another
federal agency (if applicable)
Your Institution’s
Unique Case
Identifier: (if
applicable)

Incident
Number

ORI’s assigned
identification (ORI
case number or
accession number,
as applicable):

Type of Activity

Agency’s
Type of
Type of
Type of
Agency Name
Unique
Misconduct: Misconduct: Misconduct: (e.g. NSF, DOD,
Case
Fabrication Falsification Plagiarism VA, etc)
Identifier

Assessment
1.

Inquiry
Investigation
Assessment

2.

Inquiry
Investigation
Assessment

3.

Inquiry
Investigation

OF

2. Activity begun in 2027:

Your Institution’s
Unique Case
Identifier: (if
applicable)

Incident
Number

1.

ORI’s assigned
identification (ORI
case number or
accession number,
as applicable):

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Allegation

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Agency’s
Type of
Type of
Type of
Agency Name
Unique
Misconduct: Misconduct: Misconduct: (e.g. NSF, DOD,
Case
Fabrication Falsification Plagiarism VA, etc)
Identifier

N
G
SI
Type of Activity

Misconduct activity in
conjunction with another
federal agency (if applicable)

Assessment
Inquiry

Investigation
Allegation

2.

Assessment
Inquiry
Investigation
Allegation

3.

Assessment
Inquiry
Investigation

SECTION III: Identify the person responsible for serving as the Research Integrity Officer (42 CFR § 93.233).
NAME OF OFFICIAL
TELEPHONE NUMBER
(
)
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E-MAIL ADDRESS

SECTION IV: Identify the person responsible for assuring that the institution fosters a research environment that promotes research
integrity and the responsible conduct of research and discourages research misconduct.
NAME OF OFFICIAL
TELEPHONE NUMBER
(
)
-

PHS-6349 (Rev. 08/25)

E-MAIL ADDRESS

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This is a DESIGN PROOF ONLY. Any fields and/or checkboxes
are non-functional and for position only. Functional fields will be
inserted by technical staff once the form design is approved.
SECTION V. CERTIFICATION
I certify that the information provided in this form is complete and accurate to the best of my knowledge.
INSTITUTION CERTIFYING OFFICIAL NAME

TITLE

SIGNATURE DATE (mm/dd/yyyy)
TELEPHONE NUMBER
(
)
-

E-MAIL ADDRESS

STATEMENT OF BURDEN

RETURN THIS FORM TO:

Public reporting burden for this collection of information is estimated to average 10 minutes to
complete the form, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to: PRA@hhs.gov and to: Office of
Management and Budget, Paperwork Reduction Project (0937-0198) Washington, D.C. 20502.
Please do not return this form to either of these addresses.

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PHS-6349 (Rev. 08/25)

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Phone: (240) 453-8400
E-Mail: ORI_Assurance@hhs.gov

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Assurance Program
Office of Research Integrity
1101 Wootton Parkway, Suite 240
Rockville, MD 20852