DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service Commissioned Corps

INTRAMURAL TRAINING AGREEMENT

A. I understand that Department Health and Human Services (HHS) policy prohibits acceptance of contributions to salary, from whatever source, by active-duty officers of the Public Health Service Commissioned Corps (Corps), unless the contributions are accepted to the benefit of the Government. If accepted, the contributions are deposited to the Miscellaneous Receipts of the Treasury of the United States. Further, with regard to the training I am to receive, I have read and agree to the following:

If the HHS-supported intramural training program includes one or more periods of extramural training (i.e., training received in non-HHS facilities), I voluntarily agree to serve on active duty with the Corps for six (6) months or twice the period of training received in non-HHS facilities, whichever is greater, subject to the following limitations: (a) If the total period of training in non-HHS facilities is 30 days or less, I incur no active-duty obligations; (b) Up to one (1) year of training in non-HHS facilities, for which no tuition and fees are charged, shall be disregarded in determining the period of my active-duty obligation.

My active-duty obligation shall commence immediately upon cessation of my participation in the training program. Failure to fulfill my active-duty obligation shall subject me to the penalties set forth in Paragraph B below. (See CC25.2.1 and CC25.2.2 of the electronic Commissioned Corps Issuance System.)

B. I understand that if I fail to complete an active-duty obligation with the Corps incurred as a result of training received in non-HHS facilities as set forth in Paragraph A, above, I shall be obligated to pay HHS an amount equal to two (2) times the total amount of the tuition, fees, and other training expenses and two (2) times any compensation (to include but not limited to pay, allowances, special pays, travel, transportation, and shipment of household goods) received by me or paid on my behalf in connection with the training. Under Department of the Treasury regulations, late charges may be assessed for payments made after the due date on amounts owed to the U.S. Government. Furthermore, I understand that if I fail to fulfill an active-duty obligation incurred pursuant to my participation in training under this agreement, HHS will deny lump-sum payment of unused annual leave and transportation allowances and travel time which are otherwise authorized in connection with separation from the Corps; withhold my final pay and allowances to satisfy any indebtedness to the Government; and deny my request for a commission in the Ready Reserve.

STATE FIELD OF STUDY OR SPECIALTY

NAME (Typed) LAST FIRST MI

SIGNATURE DATE

PHS-6374 (Rev. 8/16) PSC Publishing Services (301) 443-6740 EF

FORM PHS-6374

HHS/PHS

Intramural Training Agreement

PSC Publishing Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service Commissioned Corps

Commissioned Corps of the U. S. Public Health Service.

INTRAMURAL TRAINING AGREEMENT

A.

I understand that Department Health and Human Services (HHS) policy prohibits acceptance of contributions to salary, from whatever source, by active-duty officers of the Public Health Service Commissioned Corps (Corps), unless the contributions are accepted to the benefit of the Government. If accepted, the contributions are deposited to the Miscellaneous Receipts of the Treasury of the United States. Further, with regard to the training I am to receive, I have read and agree to the following:

I understand that Department Health and Human Services (H H S) policy prohibits acceptance of contributions to salary, from whatever source, by active duty officers of the Public Health Service Commissioned Corps (Corps), unless the contributions are accepted to the benefit of the Government and are deposited to the Miscellaneous Receipts of the Treasury of the United States. Further, with regard to the training I am to receive, I have read and agree to the following:

If the HHS-supported intramural training program includes one or more periods of extramural training (i.e., training received in non-HHS facilities), I voluntarily agree to serve on active duty with the Corps for six (6) months or twice the period of training received in non-HHS facilities, whichever is greater, subject to the following limitations: (a) If the total period of training in non-HHS facilities is 30 days or less, I incur no active-duty obligations; (b) Up to one (1) year of training in non-HHS facilities, for which no tuition and fees are charged, shall be disregarded in determining the period of my active-duty obligation.

If the H H S supported intramural training program includes one or more periods of extramural training (i. e., training received in non H H S facilities), I voluntarily agree to serve on active duty with the Corps for six (6) months or twice the period of training received in non H H S facilities, whichever is greater, subject to the following limitations: (a) If the total period of training in non H H S facilities is 30 days or less, I incur no active duty obligations; (b) Up to one (1) year of training in non HHS facilities, for which no tuition and fees are charged, shall be disregarded in determining the period of my active duty obligation.

My active-duty obligation shall commence immediately upon cessation of my participation in the training program. Failure to fulfill my active-duty obligation shall subject me to the penalties set forth in Paragraph B below. (See CC25.2.1 and CC25.2.2 of the electronic Commissioned Corps Issuance System.)

My active duty obligation shall commence immediately upon cessation of my participation in the training program. Failure to fulfill my active duty obligation shall subject me to the penalties set forth in Paragraph B below. (See C C 25.2.1 and C C 25.2.2 of the electronic Commissioned Corps Issuance System.)

B.

I understand that if I fail to complete an active-duty obligation with the Corps incurred as a result of training received in non-HHS facilities as set forth in Paragraph A, above, I shall be obligated to pay HHS an amount equal to two (2) times the total amount of the tuition, fees, and other training expenses and two (2) times any compensation (to include but not limited to pay, allowances, special pays, travel, transportation, and shipment of household goods) received by me or paid on my behalf in connection with the training. Under Department of the Treasury regulations, late charges may be assessed for payments made after the due date on amounts owed to the U.S. Government. Furthermore, I understand that if I fail to fulfill an active-duty obligation incurred pursuant to my participation in training under this agreement, HHS will deny lump-sum payment of unused annual leave and transportation allowances and travel time which are otherwise authorized in connection with separation from the Corps; withhold my final pay and allowances to satisfy any indebtedness to the Government; and deny my request for a commission in the Ready Reserve.

I understand that if I fail to complete an active duty obligation with the Corps incurred as a result of training received in non H H S facilities as set forth in Paragraph A, above, I shall be obligated to pay H H S an amount equal to two (2) times the total amount of the tuition, fees, and other training expenses and two (2) times any compensation (to include but not limited to pay, allowances, special pays, travel, transportation, and shipment of household goods) received by me or paid on my behalf in connection with the training. Under Department of the Treasury regulations, late charges may be assessed for payments made after the due date on amounts owed to the U. S. Government. Furthermore, I understand that if I fail to fulfill an active-duty obligation incurred pursuant to my participation in training under this agreement, H H S will deny lump sum payment of unused annual leave and transportation allowances and travel time which are otherwise authorized in connection with separation from the Corps; withhold my final pay and allowances to satisfy any indebtedness to the Government; and deny my request for a commission in the Ready Reserve.

STATE FIELD OF STUDY OR SPECIALTY

NAME (Typed) 

LAST

FIRST

MI

Middle initial.

SIGNATURE

DATE

PHS-6374 (Rev. 8/16)

P H S - 63 74 (Revised August 2016).

PSC Publishing Services (301) 443-6740

P S C Publishing Services (3 0 1) 4 4 3 - 67 40.

EF

E F.

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