Form 1 Harassment web form

OMB Control No.0925-XXXX

Expiration date xx/xx/xxxx

Inform NIH About Harassment or Discrimination Concerns

Individuals: Notify NIH about a concern that harassment or discrimination (including but not limited to sexual harassment and racial discrimination) is contributing to an unsafe or hostile work environment affecting an NIH funded project at a grantee institution

Authorized Organization Representatives (AOR): Report that an individual identified as PD/PI or other Senior/Key personnel has been removed from their position or otherwise disciplined due to concerns about harassment, bullying, retaliation or hostile working conditions? Include in the “Briefly Describe” field, at a minimum:

• Note that this is report from an AOR

• A description of the concerns

• The action(s) taken

• Any anticipated impact on the NIH-funded award(s).

While NIH can and will follow up on all notifications of concerns related to NIH-funded research, NIH cannot take personnel or legal actions on behalf of non-NIH employees. NIH strongly encourages individuals to report allegations to the appropriate authorities, which may include:

• your local police department;

• your organization/institution equal opportunity office, human resources offices, or Title IX Coordinator; and/or

• the HHS Office for Civil Rights (OCR, https://www.hhs.gov/ocr/index.html) to obtain additional information and to file a complaint.

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Anti-Harassment Privacy Notice [will link out]

Fields marked with an * are required.

Your first name (Optional for individuals, required for AORs)

Your last name (Optional for individuals, required for AORs)

Your email address (Optional for individuals, required for AORs)

Your phone number (Optional for individuals, required for AORs)

First name of the person who may have committed harassment or discrimination *

Last name of the person who may have committed harassment or discrimination *

Institution that employs that person *

Briefly describe the incident *

 Submit

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Please find additional information and resources on this webpage.

Public reporting burden for this collection of information is estimated to average 15 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-xxxx*). Do not return the completed form to this address.