Approval Request for Outside Professional Activities

							                                                                                                                             Rev. 11/07
 
                                         Approval Request for Outside Professional Activities




Name________________________________                Position_________________________                   Ext______

Directions
             •    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,                     
                  hhernandez@scripps.edu. If you have any questions regarding this form or the approval request process,
                  please contact Heather.                                                                                 


         Approval Questionnaire
    1.      Please provide the following information regarding the Business that will be using your professional services:
                                                                                                                 
            Business Name: _______________________________________________
                                                                                                                     
            Address:           _______________________________________________
            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?
                         Yes                               No                                                 
    4.      Has the Business licensed or does it seek to license technology you have developed at TSRI?  
                         Yes                                No

    5.      Will the new activity fall within the scope of any of your current research projects at TSRI?
                         Yes                                No                              

    6.      Does the activity involve the design, conduct or reporting of a clinical trial?
                          Yes                               No

    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?
                         Yes                                No