Phs-7091 Research Integrity Assurance Establishment Form

Form Approved
OMB No. 0937-0198; Expires: XXX
See Statement of Burden at bottom of form
Date Request Submitted
XXX XX, XXXX

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

RESEARCH INTEGRITY
ASSURANCE ESTABLISHMENT FORM
INSTRUCTIONS

Institutions who apply for or receive Public Health Service (PHS) support for biomedical or behavioral research, research training, or activities
related to that research or research training must provide HHS with an assurance of compliance with 42 CFR Part 93. Institutions should
complete this form to establish their assurance with the Office of Research Integrity (ORI). To complete this form, institutions must develop
and submit policies and procedures that comply with the Public Health Service (PHS) Policies on Research Misconduct at 42 CFR Part 93. If
an institution believes it qualifies as a small institution (42 CFR § 93.240), it may complete and submit the Small Institution Statement with this
form instead of developing and submitting policies and procedures. A research integrity assurance cannot be established by ORI without either
policies and procedures or the Small Institution Statement. To maintain an assurance, institutions must annually submit a Research Integrity
Assurance and Annual Report on Possible Research Misconduct form. For questions, contact ORI_Assurance@hhs.gov or call (240) 453-8400.

SECTION I. INSTITUTIONAL INFORMATION
INSTITUTION NAME
INSTITUTION STREET ADDRESS

CITY

STATE

NIH IPF NUMBER (if available)

ZIP CODE

COUNTRY

INSTITUTION UEI NUMBER (if available)

PHS FUNDING COMPONENT (if available)

SECTION II. INSTITUTIONAL CONTACTS
A. The person responsible for serving as the Institutional Certifying Official (42 CFR § 93.217):
NAME
TELEPHONE NUMBER

TITLE
EXT

EMAIL ADDRESS

B. Please add a secondary institutional contact (if applicable):
SECONDARY OFFICIAL
TELEPHONE NUMBER

TITLE
EXT

EMAIL ADDRESS

C. The person responsible for serving as the Research Integrity Officer (42 CFR § 93.233):
NAME
TELEPHONE NUMBER

TITLE
EXT

EMAIL ADDRESS

D. 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
TELEPHONE NUMBER

TITLE
EXT

EMAIL ADDRESS
(continued on next page)

PHS-7091 (08/25)

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PSC Publishing Services (301) 443-6740

EF

SECTION III: ESTABLISHMENT OF 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.
It will comply with all provisions of 42 CFR Part 93.
It has checked for an active assurance with ORI. This form is for institutions seeking to establish an ORI assurance.
Institutions with active assurances must only file the Research Integrity Assurance and Annual Report on Possible Research
Misconduct, which must be submitted to ORI annually. Institutions can check for active assurances in the Annual Report System
at ori.hhs.gov/arprm/Login.php.
CHOOSE ONE:
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 IV. CERTIFICATION
I certify that the information provided in this form is complete and accurate to the best of my knowledge.
INSTITUTIONAL CERTIFYING OFFICIAL NAME

TITLE

SIGNATURE
TELEPHONE NUMBER

DATE (mm/dd/yyyy)
EXT

EMAIL 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.

PHS-7091 (08/25)

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Assurance Program
Office of Research Integrity
1101 Wootton Parkway, Suite 240
Rockville, MD 20852
Phone: (240) 453-8400
E-Mail: ORI_Assurance@hhs.gov