Reimbursed Travel Report for Key Personnel on PHS Awards

East Hill Office Building, Suite 320 395 Pine Tree Road Ithaca, NY 14850 p. 607-254-8878 f. 607-255-0758 www.oria.cornell.edu/coi Reimbursed Travel Report for Key Personnel on PHS awards

Public Health Service (PHS) regulations require that all Investigators on PHS awards (includes NIH, FDA, CDC, etc.) issued on or after Aug 24, 2012, disclose 12 months retrospectively (to August 2011) all travel related to their institutional responsibilities, whether they were reimbursed or travel expenses were paid on their behalf. Trips must be reported within 30 days of the last day of the trip. Exclusions are noted below.

Additional information can be found on the Cornell COI website at http://www.oria.cornell.edu/COI/. Please contact the COI office at 255-2214 or [email protected] if you have any questions about this form or the requirements.

1. Please provide the following information about yourself. Name (last name, first name)

Cornell Net ID

Email address

2. Have you undertaken travel that is related to your Cornell responsibilities and reimbursed to you or paid on your behalf? Do Include: (1) Any travel that contributes to or arises out of your teaching, research, outreach, publications, clinical practice, other scholarly pursuits or Cornell administrative duties AND (2) is reimbursed or paid for by any entity other than those listed below. Examples: Travel for conference presentations, lectures, keynote speeches, consulting activities arising out of your research or academic expertise associated with your Cornell appointment, expert witness testimonies, marketing, publicity or development efforts, etc.

Do not include: (1) Travel that is not related to your Cornell responsibilities or professional consulting activities; (2) Travel that is reimbursed or otherwise paid for by these excluded entities: - Cornell University - a US Federal, state, or local government agency (eg: NIH, NSF, etc.) - a US, non-profit Institution of higher education as defined at 20 U.S.C. 1001(a) - an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institution of higher education. East Hill Office Building, Suite 320 395 Pine Tree Road Ithaca, NY 14850 p. 607-254-8878 f. 607-255-0758 www.oria.cornell.edu/coi Examples of what not to include: Vacations that you/your family paid for; travel funded by your federal, state or local government agency or sponsor, travel for teaching or lectureships at non-profit, US Universities; travel funded through your Cornell account.

Yes No

3. If you responded with a “yes” above, please answer the following questions related to each travel event

Travel Event 1 Purpose of the trip

Destination of travel (If you went to multiple locations on this trip, please list them all)

Sponsor name

Duration of travel in days from start to end of the itinerary

Travel Event 2 Purpose of the trip

Destination of travel (If you went to multiple locations on this trip, please list them all)

Sponsor name

Duration of travel in days from start to end of the itinerary

CERTIFY AND SUBMIT

Please certify that the information that you have provided in this form, is to the best of your knowledge, complete and accurate. I certify that the information I have provided in this form, is to the best of my knowledge, complete and accurate.