Form Hhs 22 PDF Details

Form HHS-22 is a required form for all individuals who are subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The form is used to request authorization from the Department of Health and Human Services (DHHS) to disclose protected health information (PHI) for research purposes. In order to ensure that PHI is protected, DHHS must approve any requests for disclosure. Complete and accurate completion of Form HHS-22 is critical in order to avoid delays or rejection of your request. This article will provide an overview of Form HHS-22, including what information is required and how to submit the form correctly.

QuestionAnswer
Form NameForm Hhs 22
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesblank hhs 22, hhs 22 pdf, form hhs 22, form hhs 22 request for property action

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

REQUEST FOR PROPERTY ACTION

Date of Request:

Initiating Organization

 

 

 

 

 

 

Custodial Code

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

Admin Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAN No.

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location of Property

 

 

 

 

 

 

 

 

Contact Name

 

 

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

Action Requested (Check one)

 

 

 

 

 

 

 

 

 

 

 

Transfer

 

New Receipt

 

Turn In

 

 

Disposition Instructions (Explain in Detail - Use Reverse Side of Form.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Receiving Organization

 

 

 

 

 

 

Custodial Code

Location

CAN No.

Barcode/Decal

Number

Serial Number

Description of Property

(Noun Name. Mfg Name, Model Number, Stock Number)

QTY

Unit of

Issue

Cond.

(see

below.)

Unit Cost

Total Cost

TOTAL

Special Processing Requirements: Project Officer Assigned

*IRM Clearance

Yes

Yes

No

PO Signature:

 

Date:

 

 

No

IRM Signature:

 

Date:

*IRM Equipment certified free of commercial software/sensitive information

Signature of Property Custodial Officer/Initiator (PCO)

Date

Property Section Only

 

 

 

 

 

 

 

Signature of Receiving Official

Date

Property Custodial File Update/Final Property Action

 

 

 

 

 

 

 

Signature of Property Accountable Officer (PAO)

Date

Initials of Property Technical/Accountable Officer

Date

 

 

 

 

 

 

Property Voucher Control Number

 

 

 

 

Condition Codes: (see FPMR 101-43.48 for definitions)

1 = New

4 = Usable

7 = Repairable

X = Salvage

S = Scrap

 

Distribution

 

 

Original - Property Accountable Officer

1

Copy - Retained by PCO

1 Copy - Retained by Requester

1

Copy - Transfer Receiving Office

HHS-22 (08/17)

PAGE 1 of 2

PSC Publishing Services (301) 443-6740 EF

INSTRUCTIONS FOR COMPLETING HHS-22

1.Date of request.

2.Identify your organization, location, room number, and telephone number.

3.Custodial area/location code.

4.Common accounting number and your administrative/custodial code.

5.Specify what you want to have done.

6.Provide DATA on the recipient.

7.Serial number or local decal number. If neither, leave blank. DO NOT COMBINE MACHINES AND FURNITURE.

8.Complete nomenclature of the item(s) stock number, model number, etc. It is necessary to adequately describe the items to insure identification.

9.Number of units.

10.Unit of issue: each, set, pkg., etc.

11.Condition code. See below.

12.Acquisition cost or best estimate.

13.Name and signature of Custodial Officer.

14.Name and signature of individual receiving property.

15.Signature of Accountable Officer or authorized representative.

16.Certification by the Accountable Officer when action has been posted to appropriate account.

17.Number assigned by the Accountable Officer.

 

 

CONDITION CODES

 

 

 

Disposal Condition Code

Brief Definition

Expanded Definition

 

 

 

1

New

Property which is in new condition or unused condition and can be used immediately

without modifications or repairs.

 

 

4

Usable

Property which shows some wear, but can be used without significant repair.

7

Repairable

Property which is unusable in its current condition but can be economically repaired.

X

Salvage

Property which has value in excess of its basic material content, but repair or

rehabilitation is impractical and/or uneconomical.

 

 

S

Scrap

Property which has no value except for its basic material content.

ADDITIONAL STEPS REQUIRED IN PMIS WHEN SEEKING APPROVAL FOR THESE TYPES TRANSFERS

TRANSFER TO NATIVE AMERICAN TRIBAL:

TRANSFER TO NON-PROFIT:

TRANSFER TO ANOTHER GOV AGENCY:

T1/T5 Status

GSA Authority Form

FACT Trading Partner

638 Contract Number

Distribution:

Original and 2

-

To Accountable Officer

1 Copy

-

To Receiving Office

1 Copy

- Hold

HHS-22 (08/17)

PAGE 2 of 2

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This form requires specific details; in order to ensure accuracy, make sure you adhere to the next suggestions:

1. The department of health and human services forms usually requires specific information to be inserted. Be sure that the next blanks are filled out:

Writing part 1 of hhs 22 forms

2. Immediately after the prior section is completed, go on to type in the relevant information in these: Special Processing Requirements, Project Officer Assigned, Yes, IRM Clearance IRM Equipment, Yes, Signature of Property Custodial, Signature of Receiving Official, Signature of Property Accountable, TOTAL, Date, Date, Property Section Only, Property Custodial File, Initials of Property, and Date.

Stage # 2 of filling in hhs 22 forms

3. This next step is related to Property Voucher Control Number, Condition Codes see FPMR for, Distribution, New, Usable, Repairable, X Salvage, S Scrap, Original Property Accountable, Copy Retained by PCO, Copy Retained by Requester, Copy Transfer Receiving Office, HHS, PAGE of, and PSC Publishing Services EF - complete each one of these blanks.

Part # 3 of filling out hhs 22 forms

People often make errors while filling out Original Property Accountable in this area. You should read again whatever you enter here.

4. It is time to proceed to the next segment! In this case you will have all these TRANSFER TO NATIVE AMERICAN TRIBAL, TRANSFER TO NONPROFIT, TRANSFER TO ANOTHER GOV AGENCY, TT Status, Contract Number, GSA Authority Form, FACT Trading Partner, Distribution, Original and, To Accountable Officer, Copy, Copy, To Receiving Office, Hold, and HHS fields to do.

Writing segment 4 in hhs 22 forms

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