Phs-7092 Institutional Record Transmittal Form

This is a DESIGN DRAFT ONLY. Any fillable fields and/or checkboxes
present in this proof are non-functional and for position only. Functional
fields will be inserted by technical staff once the form design is approved.
Form Approved
OMB No. 0937-0198; Expires: XX/XX/20XX
See Statement of Burden at bottom of form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

INSTITUTIONAL RECORD
TRANSMITTAL FORM
INSTRUCTIONS

Complete and submit this form with the materials requested by the Office of Research Integrity (ORI) at the conclusion of institutional research
misconduct proceedings. Transmit this form and the accompanying materials through ORI’s file transfer system. Please contact the Director of
the ORI Division of Investigative Oversight with any questions or call (240) 453-8800.
NAME OF INSTITUTION
ORI / DIO ACCESSION NUMBER

DATE OF FINAL REPORT SUBMISSION (mm/dd/yyyy)

SECTION I. INSTITUTIONAL RECORD

Research Integrity Officers must complete this section.
I certify that my institution is submitting all items required for completing institutional research misconduct proceedings in accordance with the
Public Health Service Policies on Research Misconduct (42 CFR Part 93). The institutional record encompasses documentation and reporting
of an institutional assessment, inquiry, and/or investigation, as applicable (§ 93.220). Include the written decision from the Institutional Deciding
Official, if applicable (§ 93.314). I certify that I have included with this form:
All items encompassing the institutional record.

Please provide the Research Integrity Officer’s contact information below.
NAME (first name and last name)
ADDRESS 1
CITY
TELEPHONE NUMBER

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DE

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F
A

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SECTION II. RESEARCH INTEGRITY OFFICER

ADDRESS 2

STATE/PROVINCE ZIP CODE/COUNTRY CODE

COUNTRY

E-MAIL ADDRESS

RESEARCH INTEGRITY OFFICER SIGNATURE

STATEMENT OF BURDEN
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.

RETURN THIS FORM TO:
Please attach this form when submitting your final
report in the ORI file transfer system.
For more information, contact:
Office of Research Integrity
Division of Investigative Oversight
1101 Wootton Parkway, Suite 240
Rockville, MD 20852
Phone: (240) 453-8800

PHS-7092 (08/25)

PSC Publishing Services (301) 443-6740

EF