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Investigator Travel Disclosure Form


John Muir Health’s Conflict of Interest in Research Policy and Federal Regulation 42 CFR Part 50 Subpart F require the disclosure of Investigator travel if it meets the requirements below. Disclosure must be submitted within 30 days of travel. 
This question requires a valid date format of MM/DD/YYYY.
2. Investigator Name: *This question is required.
3. Is the travel related to the Investigator’s Institutional Responsibilities as defined in the Policy *This question is required.
4. Is the travel paid for by JMH?  *This question is required.
5. Is the travel paid for by a federal, state, or local government agency?  *This question is required.
6. Is the travel paid for by an Institution of higher education, an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institution of higher education?  *This question is required.