Review Form for NIH-Related Activities, Personal Capacity (Outside) Activities,

or Awards for Trainees

Name of Trainee: IC:

Trainee Status: IRTA CRTA VF

Office Address:


City : State : Zip :

NIH phone: Cell phone :


Supervisor: Title :

Supervisor contact Information

Telephone: Fax :

Cell : eMail :


Nature of Activity


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



NIH-Related Activity

Separate administrative approval may be required for travel outside of NIH.

Entity Name: Date(s) of Activity:

Street: City, state Zip:

Description of Activity:

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


Personal Capacity Activity

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.


Awards* [Some awards will have income tax consequences!]

*For on-the-spot meeting awards only, review may be retrospective

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


Review and Signatures


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: _________________________



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: _________________________



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: _________________________



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:



May 18, 2009