Approval Request for Outside Professional Activities
Name________________________________ Position_________________________ Ext______
• This form is for requesting approval for Outside Professional Activities under Section 5.4H of TSRI’s
Policy on Conflicts of Interest and Commitment: http://coi.scripps.edu.
• Complete this form and return it, along with any agreements and/or relevant documents, to Heather
Hernandez, Compliance Manager, Research Education & Compliance, TPC-8, Ext. 4-2419,
email@example.com. If you have any questions regarding this form or the approval request process,
please contact Heather.
1. Please provide the following information regarding the Business that will be using your professional services:
Business Name: _______________________________________________
City, State, ZIP _______________________________________________
Contact Person: _____________________________ Telephone: _____________________
2. Description of proposed Outside Professional Activity:
Scientific Consulting Scientific Advisory Board Board of Directors
Expert Witness Founding a Business Other
If other, please describe the activity: ______________________________________________________
3. Does the Business fund or seek to fund any of your research at TSRI?
4. Has the Business licensed or does it seek to license technology you have developed at TSRI?
5. Will the new activity fall within the scope of any of your current research projects at TSRI?
6. Does the activity involve the design, conduct or reporting of a clinical trial?
7. In any given year of your agreement with the Business, will you receive compensation for your services that will
either exceed $10,000 in value or represent more than a 5% ownership (equity/stock) interest in the Business?