This memorandum describes the total professional responsibilities
mutually arranged by ABC Research Corporation, EFG University and the
XYZ VA Medical Center. The combination of teaching, research,
consulting, administration, and clinical activities as of (Enter
Date) at corporation, the university and the VA medical center
comprise 100% of the total professional responsibilities as follows:
Name of Investigator:______________________________________________
| |
Type
of Responsibility |
Portion
of each type |
|
|
Total set
of responsibilities
(hours)
(% of total) |
| University |
Title:
__________________________
Department/division:
__________________________ |
Research
Teaching
Administration
Consulting
Clinical
Available University |
|
| Total
University Responsibilities |
_______________________
A
100% Univ. |
| VA
Medical Center |
Title:
__________________________
Department/division:
__________________________ |
Research
(excluding NIH)
VA merit
Teaching
Administration
Consulting
Clinical
Available VA |
|
| Total VA
Responsibilities |
_______________________
B
100% VA |
| Research
Corporation |
Title:
__________________________ |
Research
Research Consulting |
_______________________
C
100% NPC
|
| Total
Combined Responsibilities |
A+B+C
100% |
| Signatures: |
|
__________________________
Investigator |
__________________________
Associate Chief of Staff
Research & Development, VAMC |
|
__________________________
University Department Chair |
__________________________
Acting Chief of Staff, VAMC |
|
__________________________
Office of Sponsored Programs, University |
__________________________
VA Service Line Manager |
This memorandum responds to NIH Application guidelines as stated in
the NIH Guide, Vol. 10, No. 27, August 11, 1989.
PQR Research and Education Foundation
Sample Memorandum of Understanding
Faculty Receiving Salary from PQR, VA and University
All faculty receiving any percentage of their salary from PQR
Research Corporation must complete this form. This memorandum is
required to comply with university, VA and PQR policy. This
understanding establishes the salary distribution for the named faculty
member and prevents the possibility of dual compensation. Please update
as salary or distribution changes. At a minimum, this MOU must be
renewed annually.
Faculty Member:
_______________________________________________________________________
University Title:
_______________________________________________________________________
VAMC Title:
_______________________________________________________________________
PQR Title:
_______________________________________________________________________
|
Distribution
of Total Professional Salary |
Faculty
NIH Salary Support |
| University
Salary |
$
________________ |
Grant
# Salary $ % Effort |
University |
PQR |
Effective
Date |
| VAMC
Salary |
$
________________ |
_________ |
_________ |
_________ |
| PQR
Salary |
$
________________ |
_________ |
_________ |
_________ |
| Total
Salary |
$
________________ |
_________ |
_________ |
_________ |
| Indicate
any salary that will be charged to a PQR grant through a JPA with
the university. $ ______________________ |
| Obtain
signatures in the following order: |
Signature |
Date |
| 1.
Investigator (request) |
_____________________ |
___________ |
| 2. VA
Service Chief (approval) |
_____________________ |
___________ |
| 3. Univ.
Department Chair (approval) |
_____________________ |
___________ |
| 4. PQR
Executive Director (approval) |
_____________________ |
___________ |
| 5. VA Chief
of Staff (approval) |
_____________________ |
___________ |
| 6. Dean's
Office (acknowledge) |
_____________________ |
___________ |
After obtaining all signatures, return form to PQR
office
