Name of Trainee: IC:

Trainee Status: IRTA CRTA VF

Office Address:

Street:

City : State : Zip :

NIH phone: Cell phone :

eMail:

Supervisor: Title :

Supervisor contact Information

Telephone: Fax :

Cell : eMail :

1. NIH-Related Activity (uncompensated):

Speaking Writing Professional Society Activity Scientific Collaborations

2. Personal Capacity Activity, compensated (financial compensation not possible for VFs without consultation with DIS and exemption from DDIR):

Teaching Clinical Practice Data Safety Boards Speaking Other

3. Award:

Meeting (regularly given) Meeting (on the spot) Professional Society Other

Entity Name: Date(s) of Activity:

Street: City, state Zip:

Description of Activity:

Duration of Activity: Is travel outside NIH required? Yes No

Entity Name: Date(s) of Activity:

Street: City, state Zip:

Description of Activity:

Is activity compensated? Yes No Compensation Amount:

Funding source: Time commitment: ___hrs ___days ___weeks

Start date: End date:

Is there a potential for conflict of interest? Yes No

If YES, please explain.

Is travel required? Yes No

If YES, please explain arrangements.

If clinical practice, describe credentials and attach supplemental form for moonlighting.

Entity providing award: Date(s) of Award Event:

Street: City, state Zip:

Full Name of Award: If cash award, what is the amount?

If no cash, what is the nature of the award? Award selection criteria:

Is travel outside NIH required? Yes No

Lab/Branch chief:

I have discussed the NIH Guidelines for Trainees with ____________________, who is a______________ in my laboratory and approve of this activity.

Name: ____________________________________ Date: _________________________

Signature:

Scientific Director (if necessary):

I have reviewed and discussed the appropriateness of this activity with the trainee named in this document. I approve the request.

Name: ____________________________________ Date: _________________________

Signature:

DEC/EC for _____________ (if necessary)

We have reviewed and approved this request. The form will be returned to the trainee to be included in his/her file. If I have any concerns with potential COI, I will contact the Senior Scientific Advisor in the NEO.

Name: ____________________________________ Date: _________________________

Signature:

NEO Sr. Scientific Advisor (if necessary):

I have reviewed the criteria for this award and find no conflicts.

the potential for COI and find no conflicts for acceptance.

Name: Melissa C. Colbert, PhD

Signature: Date: