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Department of Veterans Affairs

REQUESTS FOR APPROVAL OF ACCEPTANCE OF GIFTS OR DONATIONS FOR TRAVEL/SUBSISTENCE EXPENSES IN CONNECTION WITH OFFICIAL TRAVEL BY VHS&RA FACILITY EMPLOYEES

NOTE TO REQUESTING EMPLOYEE AND SUPERVISOR: Before completing this request you should review the Administrator's Memorandum to All VA Employees dated May 7, 1984, Subject: Conflict of Interest: Director for Operation Letter dated October 28, 1985, Subject: Conflict of Interest: and VHS&RA Manual M-8, "Academic Affairs," Part V. Chapter 5.

Address questions about this form: Administrative Operations Staff (143D), Office of Academic Affairs, VACO. FTS 389-5175.

PART 1. EMPLOYEE REQUEST:

1. NAME: (Full Name, Office, and Symbol):

____________________________________________________________
____________________________________________________________

2. DATES OF TRAVEL:

____________________________________________________________
____________________________________________________________

3. DESTINATION (City and State):

____________________________________________________________
____________________________________________________________

4. DONOR ORGANIZATION (Name, Address, and Employer Number):

____________________________________________________________
____________________________________________________________

5. BASIS OF ACCEPTANCE (Check One):

  1. Acceptance of cash from a 501(c)(3) approved organization.
  2. Acceptance of support in kind from a 501(c)(3) approved organization.
  3. Acceptance from State, County, or Municipal Government.
  4. Acceptance of cash by a VHS&RA "Nationally Recognized Principal Investigator".
    (If acceptance is as a VHS&RA "Nationally Recognized Principal Investigator," state specific criteria supporting such status:
    ____________________________________________________________
    ____________________________________________________________
  5. Acceptance in kind from a non-501(c)(3) organization.
    [NOTE: The term "501 (c) (3) approved organizations" refers to the Internal Revenue Code and a list of tax-exempt organizations.]

6. ESTIMATED VALUE OF REQUEST (NO HONORARIUM OR COMPARABLE PAYMENT CAN BE ACCEPTED):

  1. Transportation (air, rail, etc.)_____________________________ $ __________________
  2. Lodging ______ days at $______ per day $ __________________
  3. Meals ______ days at $______ per day $ __________________
  4. Other (local transportation, etc.)__________________________ $ __________________
  5. TOTAL ..........................................................................................$ __________________

7. PURPOSE OF EMPLOYEE REQUEST (Specify your exact role during the requested official leave period, and the exact expected outcome of your participation):

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

8. CERTIFICATION

I certify that I have read the Administrator's May 7, 1984, memorandum and the Code of Ethics for Government Service, and that my acceptance of this gift or donation is in accord with them.

____________________________________            ______________________
(Employee Signature)                                                         (Date)

 

PART II. RECOMMENDATION BY SERVICE CHIEF (only)

Upon review of the above request and based upon the employee's position and responsibilities and the purpose of the requested acceptance, I recommend as follows:

____________ Approve _________Disapprove

_________________________________________                      ______________________
(Chief, Signature, Title, Office, and Symbol) (Date)                             (Date)

 

PART III. RECOMMENDATION BY CHIEF OF STAFF OR ASSOC/ASST MCD

Upon review of the above request and based upon the employee's position and responsibilities and the purpose of the requested acceptance, I recommend as follows:

____________ Approve _________Disapprove

____________________________________________                 ______________________
(Chief of Staff or Assoc./Asst. Medical Center Director)                            (Date)

 

PART IV. ACTION BY FACILITY DIRECTOR as the CMD's delegated official for approving/disapproving requests
(see MP-5, Part 1, Chapter 410):

____________ Approve _________Disapprove

____________________________________________                 ______________________
(Facility Director Signature)                            (Date)

 

PART V. REPORT OF SUPPORT RECEIVED (Complete and forward this report to the facility Director no later than 30 calendar days after completion of the approved trip. Information provided will be included in the facility's RCS 10-0146):

1. CASH RECEIVED

a. Transportation $______________
b. Lodging $______________
c. Meals $______________
d. Other $______________
e. Total............................... $______________

2. IN KIND EQUIVALENT

a. Transportation $______________
b. Lodging $______________
c. Meals $______________
d. Other $______________
e. Total............................... $______________

 

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last updated: 01/04/10

 

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