or Awards for
Name of Trainee:
City : State
: Zip :
NIH phone: Cell
Supervisor contact Information
Nature of Activity
1. NIH-Related Activity (uncompensated):
2. Personal Capacity Activity, compensated (financial
compensation not possible for VFs without consultation with DIS
and exemption from DDIR):
Safety Boards Speaking
Meeting (on the
Separate administrative approval may be
required for travel outside of NIH.
Date(s) of Activity:
Description of Activity:
Duration of Activity: Is
travel outside NIH required?
Is activity compensated?
Time commitment: ___hrs ___days ___weeks
Is there a potential for conflict of interest?
If YES, please explain.
Is travel required?
If YES, please explain arrangements.
If clinical practice, describe credentials and attach
supplemental form for moonlighting.
*For on-the-spot meeting awards only, review
may be retrospective
Entity providing award:
Date(s) of Award Event:
Full Name of Award:
If cash award, what is the amount?
If no cash, what is the nature of the award?
Is travel outside NIH required?
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
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.
NEO Sr. Scientific Advisor (if necessary):
I have reviewed
the criteria for
this award and find no conflicts.
for COI and find no conflicts for acceptance.
Name: Melissa C. Colbert, PhD