Instructions: Insert appropriate text in the [brackets]. Remove all brackets and instructions. Confirm format is correct, e.g., signature lines are correct. Print on letterhead.

[Date]

TO:	Raynard S. Kington, M.D., Ph.D.

Deputy Director, NIH, and Deputy Ethics Counselor, NIH

FROM:	[Name of Employee Submitting Request]

[Employee's Title]

SUBJECT:	Request for Approval of Official Duty Activity

This is to request that the following activity be approved as an official duty activity. I understand that no honorarium or other remuneration may be accepted. [Insert sentence if appropriate: An HHS-348, sponsored travel request, is being submitted via the appropriate channels.]

Organization/	[Full Name of outside organization]

Address	[Full address]

Nature of Activity:	[Describe, i.e., Federal Liaison, member of advisory group, etc. Give full name of committee or group.]

Time Frame Involved:	[Month/day/year to month/day/year]

Estimated Time Involved:	[Approximate number of days per year, including travel and preparation time.]

Travel Expenses Paid by:	[Indicate IC or organization; if the organization pays, submit an HHS- 348 and insert appropriate sentence to paragraph above.]

Benefit to the Government:	[You must include a brief, meaningful description of the benefit to the Government.]

[Type Employee's Name]

Recommendation of Supervisor: (omit for IC Directors)

Approve

______ Disapprove

[Type Supervisor Name]	Date

Decision by Deputy Ethics Counselor:

Approved

______ Disapproved

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

Deputy Ethics Counselor, NIH

ODA-TOP5.wpd (1/06)