Memorandum On Travel Form

For researchers traveling on NIH or PHS funded research

This form is to be completed by all researchers with pending proposals or active National Institutes of Health (NIH) or Public Health Service (PHS) awards. It is also to be completed for research funded by other entities that apply NIH/PHS financial conflict of interest rules.

According to PHS regulations on financial conflict of interest, reimbursed or sponsored travel can be a Significant Financial Interest that gives rise to a Financial Conflict of Interest. Under the University’s Conflict of Interest Regulatory Compliance Guidelines (PDF), which set forth the University’s approach under its own Conflict of Interest Policy to the PHS regulations on financial conflict of interest, a Significant Financial Interest exists for a Covered Researcher based on reimbursed or sponsored travel if:

1. The Covered Researcher and/or the Covered Researcher’s spouse and/or the Covered Researcher’s dependent children have engaged in reimbursed or sponsored travel related to the Covered Researcher’s institutional responsibilities during the prior twelve month period; and
2. The value of all such reimbursed and sponsored travel from any one entity exceeds $5,000 when aggregated; provided, however, that travel that is reimbursed or sponsored by the University, by a Federal, state, or local government agency, by another non-profit institution of higher education accredited by a nationally recognized accrediting agency or institution, or by an academic teaching hospital, medical center, or research institute affiliated with such an institution of higher education does not constitute a Significant Financial Interest.

Institutional responsibilities to the University include research and scholarship, teaching and instruction, administrative service to the University, institutional committee membership and all other work and activities the University considers in its review of a faculty or staff member’s performance as a University employee.

Form Instructions

In order to enable the University to identify conflicts of interest presented by research and sponsored travel under the PHS regulations, you must complete the Memorandum on Travel form available on the second half of this page.

• Include – Travel reimbursed or paid for by any entity other than those listed below.

• Do Not Include – Travel that is reimbursed or sponsored by the University, by a Federal, state, or local government agency, by another non-profit institution of higher education accredited by a nationally recognized accrediting agency or institution, or by an academic teaching hospital, medical center, or research institute affiliated with such an institution of higher education.

•  Submission with Proposal – You must submit the form in conjunction with each proposal you submit to the Office of Research for funding by a PHS Agency or by another entity that applies the PHS regulations on financial conflict of interest.

• Conditions for Resubmission – In the event that all of the following conditions are satisfied at any time after you initially submit the form, you must resubmit the form within 15 days of the date of the travel that causes the conditions to be satisfied:

1. You, and/or your spouse, and/or your dependent children engage in travel related to your institutional responsibilities after you initially submit this form.
2. The travel is sponsored and/or reimbursed by an entity other than the University, a Federal, state, or local government agency, another non-profit institution of higher education accredited by a nationally recognized accrediting agency or institution, or an academic teaching hospital, medical center, or research institute affiliated with such an institution of higher education.
3. At the time of the travel, you are engaged in research or have pending a proposal for research that is funded by a PHS Agency or by another entity that applies the PHS regulations on financial conflict of interest.
4. The travel causes the value of all travel sponsored and/or reimbursed by the entity for you, and/or your spouse, and/or your dependent children, when aggregated over the preceding twelve months, to first exceed $5,000.