<p> VA/OHSU Research IPA Coversheet</p><p>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.</p><p>1. Employee Name: 2. Title/Role: </p><p>3. OHSU Employee ID: 4. OHSU Department Name: </p><p>5. VA PI Name: 6. OHSU Department Org Name: </p><p>7. VA Funding Source for IPA: </p><p>8. OHSU Annual 1.0 FTE Salary: 9. Proposed IPA FTE: </p><p>10. Proposed IPA Start Date: 11. Proposed IPA End Date: 12. Proposed budget for IPA Annual budget Approximated budget per pay period</p><p>Salary: Salary: Hourly Rate: </p><p>OPE @38%: OPE @38%: </p><p>Total Amount: Total Amount: </p><p>11. Is the individual a US Citizen? if no, identify VISA type </p><p>12. Status of employment? Permanent Other, please identify Required signatures:</p><p>______OHSU employee supervisor Name Signature Date</p><p>______VA employee supervisor Name (if different) Signature Date</p><p>______OHSU Department Administrator Name Signature Date</p><p>H.G. Archie Bouwer, Ph.D., ______Deputy ACOS, VA Research & Development Signature Date</p><p>Routing: OHSU RGC  VA R&D (Supv Budget Analyst)  VA HRMS  VAMC Director  VA R&D (Supv Budget Analyst) </p><p>Revised 8-17-11</p>