1. Is the sponsoring organization using Federal Funds to defray the costs of this trip?
   Yes No (If yes, reimbursement may NOT be accepted)
   Date verified
   Person Verifying
   
   
2. Does the offer of travel reimbursement include other compensation from the sponsor in (a) the form of an honorarium, or (b) payment for the travel of family members or (c) payment for travel beyond that allowed under Federal travel regulations?
   Yes No   (If yes at (b), family member's travel order # , at (c), justification attached.)
   
   
3. Is the travel unrelated to official government business as prescribed in NIH Manual 1500 Chapter 08?
   Yes No
   
   
4. Why can't this trip be paid for with DHHS funds?
   
   
   
5. Is the travel related to the development by the sponsor of a grant or contract proposal for submission to your IC?
   Yes No
   
   
6. Are there current plans for the development of a CRADA with the sponsoring organization?
   Yes No
   
   
7. Is the traveler an officer, director, trustee, partner or an employee of the sponsoring organization?
   Yes No
   
   
8. Do you or your spouse or minor child have financial interests or personal business relationships with the sponsoring organization?
   Yes No
   
   
9. Do you have any involvement in the review, approval, or monitoring of any active or potential grant, cooperative agreement, or contract (for research, goods, or services) concerning the sponsoring organization? Further, does the acceptance of this sponsorship compromise the IC's or NIH with respect to its policies, procedures, and official positions on issues?
   Yes No
   
   
10. Is the sponsor involved in any NIH investigations of scientific fraud or misconduct or for any reason been debarred from receipt of government grants, contracts or cooperative agreements? Is the purchase of the travel to participate in an activity involving scientific misconduct issues? If the answer is "yes," please discuss the circumstances with your Executive Officer before proceeding.
    Yes No

Information above is accurate and complete to best of my knowledge and in accordance with NIH Manual 1500 Chapter 08.

* Is your answer to any of the questions above "yes" as it pertains to any sponsor on this Travel Order? If so, please provide an explanation for each "yes" answer for each sponsor as an attachment to this Checklist. If all of your answers to the above questions are "no", you do not need to seek ethical clearance.