IPA Checklist Cover Sheet (Portland VA Medical Center)

VA/OHSU Research IPA Coversheet

The purpose of a VA/OHSU Research IPA is for VA Pricipal Investigators to purchase the services of OHSU personnel necessary to complete work on VA research projects. For questions contact: Heather Trevisanut, VA Research & Development at 503-220-8262 extension 54195.

1. Employee Name: 2. Title/Role:

3. OHSU Employee ID: 4. OHSU Department Name:

5. VA PI Name: 6. OHSU Department Org Name:

7. VA Funding Source for IPA:

8. OHSU Annual 1.0 FTE Salary: 9. Proposed IPA FTE:

10. Proposed IPA Start Date: 11. Proposed IPA End Date: 12. Proposed budget for IPA Annual budget Approximated budget per pay period

Salary: Salary: Hourly Rate:

OPE @38%: OPE @38%:

Total Amount: Total Amount:

11. Is the individual a US Citizen? if no, identify VISA type

12. Status of employment? Permanent Other, please identify Required signatures:

______OHSU employee supervisor Name Signature Date

______VA employee supervisor Name (if different) Signature Date

______OHSU Department Administrator Name Signature Date

H.G. Archie Bouwer, Ph.D., ______Deputy ACOS, VA Research & Development Signature Date

Routing: OHSU RGC  VA R&D (Supv Budget Analyst)  VA HRMS  VAMC Director  VA R&D (Supv Budget Analyst)

Revised 8-17-11