1 NIH Harassment Webform

OMB Control No.0925-XXXX

Expiration date xx/xx/xxxx

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.

Institutions: Inform NIH About Harassment or Discrimination Concerns

Authorized Organization Representative (AOR): Notify NIH 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. The AOR must provide their name and contact information. Please include, at a minimum, the following in the "Briefly describe the incident" field:

• Note that this report is from an AOR

• A description of the concerns

• The action(s) taken, including a timeline of events

• Any anticipated impact on the NIH-funded award(s) with grant number(s)

Top of Form

All fields required

Your first name 

Your last name 

Your email address 

Your phone number

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