Instructions: Insert names, credentials, and other requested information as noted below. Tailor the text as needed to fit your situation. Remove instructions and brackets. Print on letterhead. Additional information on the NIH Ethics Program web site. http://ethics.of.nih.gov/topics/official.htm

TO:	[insert name]

[insert title]

FROM:	Name

Title, Office

SUBJECT:	Official Duty Activities

I write to request permission to engage in certain official duty activities with outside organizations. This list is only illustrative and not exhaustive. If I am uncertain whether an activity falls within this authorization, I will seek further instruction from you.

I understand that additional clearances may be needed for other aspects of an activity. Such additional clearances may be necessary for:

•	Acceptance of travel, either paid for or accepted from an outside source by the NIH and may include local travel to and from the airport and the site of the meeting;

•	Acceptance of gifts, including meals (individually or at a widely attended gathering) or those associated with bona fide awards; and/or

•	Service on a board of directors or as an officer of, or a federal liaison to, the outside organization.

No additional clearance is needed when I am meeting other federal officials, although I understand that I must notify the legislative office in advance before I meet with legislative staff or give congressional testimony.

The types of activities that I will likely engage in are:

•	Speaking about current or proposed NIH programs, either to a small group or at academic institution or professional society's annual meeting;

•	Meeting to review program developments of the outside organization; or

•	Manuscript or journal review.

The outside organizations with whom I may meet are:

•	Grantees or contractors;

•	Trade or professional groups; or

•	Industry.

When meeting with these outside groups, I will be mindful not to give the appearance of preferential treatment. Thus, I will consider like invitations from similarly situated groups.

A meeting with industry may raise other concerns, and I will carefully consider such invitations before accepting them.

I also understand that it is my responsibility not to participate in a particular matter if that matter will have a direct and predictable effect on my personal and imputed interests. For purposes of the conflicts rules, I know my interests include those of organizations for which I served as an employee, consultant, officer, trustee or director within the last year, those of my spouse's employer, and those with whom I am negotiating for employment. If I have any questions about the conflicts of interest restrictions, I will seek further guidance from the NIH Ethics Office.

Finally, I will maintain a list of completed activities covered by this approval that will be readily available if needed.

DECISION:

Approve

Disapprove

approving authority name and credentials	Date

title of (e.g., supervisor or Deputy Ethics Counselor)