Fillable SECTION A REQUEST APPROVAL OF TRAVEL RELATED EXPENSES (Uniformed Services University Maryland)

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SECTION A REQUEST APPROVAL OF TRAVEL RELATED EXPENSES (Uniformed Services University Maryland)

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  • 12 check-boxes
  • 44 other fields

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Page 1 of 2
REQUEST APPROVAL OF TRAVEL RELATED EXPENSES
Traveler’s Name:
Traveler’s Position:
Traveler’s Phone:
Traveler’s Department:
Dates of Travel:
Purpose of Travel:
Traveler’s E-mail:
Administrative POC:
Location of Travel:
INSTRUCTIONS:
Provide dollar value for each expense listed below (as applicable). If you use non-grant, non-federal
funding, you need to differentiate between reimbursement by check or in-kind reimbursement.
FUNDING
SOURCES:
GRANT OR
AGREEMENT*
FEDERAL
NON-GRANT, NON-FEDERAL**
check value OR in-kind value
Lodging
$
$
$
$
Meals
$
$
$
$
Tickets
$
$
$
$
Registration
$
$
$
$
Taxis
$
$
$
$
Other (list):
$
$
$
$
*
Grant or agreement funding includes: research grants and core funding through cooperative agreement/grant.
** Non-grant, non-Federal funding includes: endowment, special education funds, or special project funds.
Will the Traveler be Speaking/Presenting?
Yes
No
If Yes, is the registration fee waived?
Yes
No
SECTION A
SECTION B
INSTRUCTIONS:
Complete this section ONLY if you have indicated above that you are using non-grant, non-Federal funding for
any expense.
Is spouse travel being funded by the non-Federal source? (check one)
Is proffer letter attached? (check one)
YES NO
This is required for all funding from a Non-Federal Source, except the Henry Jac
YES
kson Foundation (HJF).
Name/Title of Funding Source(s):
If HJF, please provide Cost
Center Code(s) or HJF 321 Form.
YES
NO
Please confirm that the traveler has orders in DTS to be TDY for this trip:
NO
Page 2 of 2
INSTRUCTIONS:
This must be completed for all travel except when travel funds come from an Agreement/Grant.
Uniformed Services University Account Code:
I UNDERSTAND THAT:
All checks are to be made payable to the Uniformed Services University of the Health Sciences (USUHS) and
turned in to the Finance office. If the non-Federal funds are insufficient to cover my authorized expenses, the
difference will be charged to my department's organization. If the non-Federal source provides sufficient funds,
I will be fully reimbursed for travel expenses (provided they are similar to expenses for other attendees) even if
those expenses exceed the allowable rate under Volume 1 of the Joint Federal Travel Regulations.
To the best of my knowledge, accepting these funds does not present a conflict of interest, i.e., a reasonable
person with knowledge of all of the facts would not question the integrity of USUHS programs or operations.
Funded orders are required for any payments in kind or reimbursed to the University for travel.
_____________________ ____________ _________________________
TRAVELER Name Signature Date
_________________________ _____________________ ____________
DEPT. CHAIR/DEAN Name Signature Date
_________________________ _____________________ ____________
ETHICS OFFICIAL Name Signature Date
OGC Form 1 REV 1/4/19
SECTION C
INSTRUCTIONS:
Complete this section ONLY if you hav
e indicated above that you are using agreement/grant funding for any
expense.
Name of Grant/Agreement Providing Travel Funds: _______________________________________________
Grant Number/HJF Cost Center Code: ______________________________
Is a Travel Budget Line Item on Grant? (check one) YES NO
SECTION D
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SECTION A REQUEST APPROVAL OF TRAVEL RELATED EXPENSES (Uniformed Services University Maryland)

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Completed 28 August 2020

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