Investigator Travel Disclosure Form

Requirements

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.

1. Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Investigator Name: *This question is required.

First Name *This question is required.

Last 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.