Form Approved Through 10/31/2018 OMB No. 0925-0002

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Procedure for Submission of Final Invention Statement and Certification (For Grant or Award)

Form HHS 568

A Final Invention Statement and Certification (Form HHS 568) shall be executed and submitted within 90 days following the expiration or termination of a grant or award. The Statement shall include all inventions which were conceived or first actually reduced to practice during the course of work under the grant or award, from the original effective date of support through the date of completion or termination. The Statement shall include any inventions reported previously for the grant or award as part of a non-competing application. This reporting requirement is applicable to grants and awards by Department of Health and Human Services in support of research.

The Final Invention Statement and Certification does not in any way relieve the person responsible for the grant or award, or the institution, of the obligation to assure that all inventions are promptly and fully reported directly to the National Institutes of Health, as required by terms of the grant or award. Information regarding the reporting of inventions, including the reporting form to be followed, may be obtained from the Office of Policy for Extramural Research Administration, Division of Extramural Inventions and Technology Resources, 6705 Rockledge Drive MSC 7980, Bethesda, Maryland 20892-7980, Telephone: (301) 435-1986.

The original of the completed Final Invention Statement and Certification is to be returned to the awarding component that funded the grant or award. The entire grant or award number must appear in the designated box on the form. The period covered by the Final Invention Statement is the project period of the grant or award at a particular grantee institution. If no inventions were involved, insert the word “None” in the first block under item Title of Invention. Each Statement requires the signature of an institution official authorized to sign on behalf of the institution.

Public reporting burden for this collection of information is estimated to vary from 5 to 10 minutes per response, 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, ATTN: PRA (0925-0002). Do not return the completed form to this addresses.

Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the Privacy Act: NIH 09-25-0036, Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contract Information (DCIS), and Cooperative Agreement Information, HHS/NIH : http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm .

HHS 568 (Rev. 06/15) — Instructions

http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm

Form Approved Through 10/31/2018 OMB No. 0925-0002

Department of Health and Human Services Final Invention Statement and Certification

(For Grant or Award

DHHS Grant or Award No.

A. We hereby certify that, to the best of our knowledge and belief, all inventions are listed below which were conceived and/or first actually reduced to practice during the course of work under the above-referenced DHHS grant or award for the period

original effective datethrough

date of termination .

B. Inventions (Note: If no inventions have been made under the grant or award, insert the word “NONE” under Title below.)

NAME OF INVENTOR TITLE OF INVENTION DATE REPORTED TO DHHS

(Use continuation sheet if necessary)

C. Signature — This block must be signed by an official authorized to sign on behalf of the institution. Title

Typed Name

Name and Mailing Address of Institution

Signature Date

HHS 568 (Rev. 06/15)

FORM HHS-568

PSC Publishing Servcies

Procedure for Submission of Final Invention Statement and Certification (For Grant or Award) Form HHS 568

HHS/HHS

Form Approved Through 10/31/2018

Form Approved Through December 31, 2018.

OMB No. 0925-0002

O M B Number 0 9 2 5 - 0 0 0 2.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Procedure for Submission of Final Invention Statement and Certification (For Grant or Award) Form HHS 568

Procedure for Submission of Final Invention Statement and Certification (For Grant or Award) Form H H S 5 68.

DHHS logo

H H S logo.

A Final Invention Statement and Certification (Form HHS 568) shall be executed and submitted within 90 days following the expiration or termination of a grant or award. The Statement shall include all inventions which were conceived or first actually reduced to practice during the course of work under the grant or award, from the original effective date of support through the date of completion or termination. The Statement shall include any inventions reported previously for the grant or award as part of a non-competing application. This reporting requirement is applicable to grants and awards by Department of Health and Human Services in support of research.

A Final Invention Statement and Certification (Form H H S 5 68) shall be executed and submitted within 90 days following the expiration or termination of a grant or award. The Statement shall include all inventions which were conceived or first actually reduced to practice during the course of work under the grant or award, from the original effective date of support through the date of completion or termination. The Statement shall include any inventions reported previously for the grant or award as part of a non competing application. This reporting requirement is applicable to grants and awards by Department of Health and Human Services in support of research.

The Final Invention Statement and Certification does not in any way relieve the person responsible for the grant or award, or the institution, of the obligation to assure that all inventions are promptly and fully reported directly to the National Institutes of Health, as required by terms of the grant or award. Information regarding the reporting of inventions, including the reporting form to be followed, may be obtained from the Office of Policy for Extramural Research Administration, Division of Extramural Inventions and Technology Resources, 6705 Rockledge Drive MSC 7980, Bethesda, Maryland 20892-7980, Telephone: (301) 435-1986.

The Final Invention Statement and Certification does not in any way relieve the person responsible for the grant or award, or the institution, of the obligation to assure that all inventions are promptly and fully reported directly to the National Institutes of Health, as required by terms of the grant or award. Information regarding the reporting of inventions, including the reporting form to be followed, may be obtained from the Office of Policy for Extramural Research Administration, Division of Extramural Inventions and Technology Resources, 67 0 5 Rockledge Drive M S C 79 80, Bethesda, Maryland 2 0 8 9 2 - 79 80, Telephone: (3 0 1) 4 3 5- 19 86.

The original of the completed Final Invention Statement and Certification is to be returned to the awarding component that funded the grant or award. The entire grant or award number must appear in the designated box on the form. The period covered by the Final Invention Statement is the project period of the grant or award at a particular grantee institution. If no inventions were involved, insert the word “None” in the first block under item Title of Invention. Each Statement requires the signature of an institution official authorized to sign on behalf of the institution.

Public reporting burden for this collection of information is estimated to vary from 5 to 10 minutes per response, 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, ATTN: PRA (0925-0002). Do not return the completed form to this addresses. 

Public reporting burden for this collection of information is estimated to vary from 5 to 10 minutes per response, 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 O M B control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: N I H, Project Clearance Branch, 67 0 5 Rockledge Drive M S C 79 74, Bethesda, Maryland 2 0 8 9 2 - 7 9 7 4, Attention: P R A (0 9 2 5 - 0 0 0 2). Do not return the completed form to this addresses.

Privacy Act Statement.   The NIH maintains application and grant records as part of a system of  records as defined by the Privacy Act:  NIH 09-25-0036,  Extramural Awards and Chartered  Advisory Committees (IMPAC 2), Contract Information (DCIS), and Cooperative Agreement  Information, HHS/NIH : 

Privacy Act Statement. The N I H maintains application and grant records as part of a system of records as defined by the Privacy Act: NIH 0 9 - 25 - 0 0 36, Extramural Awards and Chartered Advisory Committees (I M P A C 2), Contract Information (D C I S), and Cooperative Agreement Information, H H S/N I H :

http://oma.od.nih.gov/ms/privacy/pa-files/0036.htm

h t t p://o m a dot o d dot n i h dot gov/m s/privacy/pa - files/0 0 3 6 dot h t m.

.

HHS 568 (Rev. 06/15) — Instructions

H H S 5 68 (Revised August 2012) — Instructions.

Form Approved Through 10/31/2018

OMB No. 0925-0002

Department of Health and Human Services

Final Invention Statement and Certification

(For Grant or Award

DHHS Grant or Award No.

D H H S Grant or Award Number.

A.

We hereby certify that, to the best of our knowledge and belief, all inventions are listed below which were conceived and/or first actually reduced to practice during the course of work under the above-referenced DHHS grant or award for the period

We hereby certify that, to the best of our knowledge and belief, all inventions are listed below which were conceived and/or first actually reduced to practice during the course of work under the above referenced D H H S grant or award for the period.

original effective date

through

date of termination

.

B.

Inventions (Note: If no inventions have been made under the grant or award, insert the word “NONE” under Title below.) 

NAME OF INVENTOR

TITLE OF INVENTION

DATE REPORTED TO DHHS

(Use continuation sheet if necessary)

C. Signature — This block must be signed by an official authorized to sign on behalf of the institution. 

Title

Typed Name

Name and Mailing Address of Institution

Signature

Date

HHS 568 (Rev. 06/15)

D H H S grant or award number: original effective date: date of termination: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: name of inventor: title of invention: date reported to D H H S: title: typed name: name and mailing address of institution: employee's signature: date of signature: