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U.S. Department of Health & Human Services National Institutes of Health Office of Extramural Research
OMB No. 0925-0361
Form Approved for use through 6/30/2017
Click here to see the burden statement

NIH 2674-15

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Social Security Number:

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Note: We collect your Social Security Number [SSN] to verify your identity, to determine your eligibility for loan repayment assistance and to keep track of the federal funds you receive. We also use your SSN for loan repayment and servicing purposes under the Loan Repayment Program. We also use this information to determine whether you are eligible for loan repayment and the amount of that assistance. See Privacy Act information for additional information.

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Public reporting for this collection of information is estimated to average 3 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.

NIH Form 2674-15
Privacy Act 09-25-0165