Forms

Outside Activities Forms

• HHS-520 (1/06), Request for Approval of Outside Activity (fillable*)
  Note: You must submit the HHS-520 electronically through NEES. The link permits viewing and printing the form as a guide to assist in submitting the form electronically. Form HHS-520, Request for Approval of Outside Activity, is used within the Department of Health and Human Services (DHHS) to request pre-approval of all proposed Outside Activities (activities that are totally outside regular official duties, and with outside organizations).
• HHS-521 (1/06) Annual Report of Outside Activity
  Note: You must submit the HHS-521 electronically through NEES. The link permits viewing and printing the form as a guide to assist in submitting the form electronically. Form HHS-521, Annual Report of Outside Activities, is used to report of all your Outside Activities in which you engaged during the previous calendar year; due February 28th each year.
• NIH Enterprise Ethics System (NEES)  (electronic submission)
  For electronically submitting Request for Approval of Outside Activity Form HHS-520 or Annual Report of Outside Activity Form HHS-521.
• NIH-2657 (1/04), Supplemental Information to the HHS-520 (fillable*)
  This NIH form is used to provide additional information for certain Outside Activities. Required for consulting for industry (complete Part B), legal consulting/testimony (complete Part C), and Professional Practice for physicians, nurses, and allied health care professionals (Complete Part D).
• Fellow Form for HHS 520 Request for Approval of Outside Activity
  For use ONLY for Outside Professional Practice for Clinical Fellows. Required with submission of HHS-520, if you are a Clinical Fellow with outside position in professional practice.
• NIH-Related Activities, Outside Activities, or Awards for Trainees Form
  For use ONLY for trainees with outside activities and awards.

Gifts/Awards Forms

• Form NIH-2854 Request for Approval to Accept Gifts Associated with an Award from an Outside Organization
  Use this form to obtain advance approval to accept gifts associated with an award from an outside organization. All employees must obtain advance approval. Use only this version (5/08).
• HHS Honorary Degree Review and Approval Form (April 1999)
  Use this form to obtain advance approval to accept an honorary degree and set the period of disqualification for the employee receiving the degree. Your Deputy Ethics Counselor will determine the permissibility of an honorary degree.

Financial Disclosure Forms

• Data Safety and Monitoring Board Conflict of Interest and Confidentiality Statement All members of the DSMB are required to be completely independent of the studies being reviewed and all members are required to sign a DSMB Conflict of Interest and Confidentiality statement.
• OGE Form 278 Public Financial Disclosure Reports
  You must submit the 278 electronically through NEES. The link permits viewing and printing the form as a guide to assist in submitting the form electronically. Form 278, Public Financial Disclosure Reports, is to assist employees and their agencies in avoiding conflicts between official duties and private financial interests or affiliations. For senior level (SES, ST, SL, O-7 and above, and others in identified positions).
• OGE Form 278-T Public Financial Disclosure Periodic Transaction Report
  Use this form as needed on a monthly basis to report transactions, e.g., stock purchase, sale, or exchange in excess of $1,000. Available in:
  • Fillable Excel format (each page of the instructions and form are separate worksheets in the file)
  • Fillable PDF , with electronic signature capability, and
  • Non-Fillable PDF (instructions and blank form).
• OGE Form 450 Confidential Financial Disclosure Reports
  You must submit the 450 electronically through NEES. The link permits viewing and printing the form as a guide to assist in submitting the form electronically. Form 450, Confidential Financial Disclosure Reports, is to assist employees and their agencies in avoiding conflicts between official duties and private financial interests or affiliations. For employees in designated positions with relevant responsibilities.
• NIH Enterprise Ethics System (NEES)  (electronic submission)
  For either Public Financial Disclosure Reports 278 or Confidential Financial Disclosure Reports 450.
• Confidential Report of Financial Interests in Substantially Affected Organizations for Employees of the NIH (HHS-717-1) (5/07)
  Note: You must submit the HHS-717-1 as a hard copy only there is no electronically through NEES. Required of all public and confidential filers, and all clinical investigators. Use this form to submit the initial report of your financial interests in Substantially Affected Organizations (SAO) and when you acquire a financial interest in an SAO (i.e., purchase, gift).

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