Instructions: Insert the appropriate text in the [brackets] and choose the relevant option for the first paragraph describing the reason for the recusal. Remove these instructions and instructions in the text below from the final document. Be sure the document is formatted correctly, i.e., signature lines look appropriate. Print on Letterhead.

[Date]

TO:	Deputy Director for Extramural Research, NIH

THROUGH:	NIH Deputy Ethics Counselor

FROM:	Director, [Insert IC's name or acronym]

SUBJECT:	Recusal from Participation in Particular Matters Involving or Affecting [insert name of entity from which you are recused]

[I have an approved outside activity or covered relationship with]

[I have a financial holding in]

[I will be receiving and award (or honorary degree) from]

As a result of consulting with appropriate government ethics staff, I understand that Federal law prohibits me from participating personally and substantially in any particular matters involving or affecting the above organization, as detailed in applicable law and regulation. Further, under the guidelines of the U.S. Department of Health and Human Services and the delegations of the National Institutes of Health, I understand that any such matters should be referred to you. Upon the execution of this document, I will distribute copies to appropriate IC staff and instruct them to refer all particular matters involving or affecting the above organization to you without consulting me or informing me that such matters are pending.

This recusal will remain in effect until I, in consultation with ethics staff, inform you in writing that it is no longer required by law or regulation.

Employee's Name/Signature

CONCUR:

Raynard S. Kington, M.D., Ph.D.	Date

NIH Deputy Ethics Counselor

ACKNOWLEDGE:

Deputy Director for Extramural Research	Date

cc:	OGC Ethics Division

IC-Director-Recusal.wpd