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Off-state degradation in drain-extended NMOS transistors is studied. Carefully designed experiments and well-calibrated simulations show that hot carriers, which are generated by impact ionization of surface band-to-band tunneling current, are responsible for interface damage during off-state stress. Classical on-state hot carrier degradation has historically been associated with broken equivSi-H bonds at the interface. In contrast, the off-state degradation in drain-extended devices is shown to be due to broken equivSi-O- bonds. The resultant degradation is universal, which enables a long-term extrapolation of device degradation at operating bias conditions based on short-term stress data. Time evolution of degradation due to broken equivSi-O- bonds and the resultant universal behavior is explained by a bond-dispersion model. Finally, we show that, under off-state stress conditions, the interface damage that is measured by charge-pumping technique is correlated with dielectric breakdown time, as both of them are driven by broken equivSi-O- bonds.