BOSTON UNIVERSITY MEDICAL CAMPUS MEMORANDUM OF UNDERSTANDING FOR JOINT APPOINTMENTS WITH AFFILIATED ORGANIZATIONS

Investigator Name: Rank/Title: Department: Teaching Research Responsibilities Example: Grant# R01 HL000000 Example: Grant# R03 MH111111 Grant# VA Merit # Grant# Grant# Clinical, Administration TOTALS:

BUMC

VABostonHS (

Other VA Institution )

Other Affiliated Organization ( )

TOTAL

Hrs/wk Hrs/wk % Hrs/wk % Hrs/wk % Hrs/wk % 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0% 0.00 0% 0.00 0% 0.00 0% 0.00

0%

APPROVALS
Investigator certification: By signing this MOU, I certify that I have indicated above all of my professional activities, including teaching, research, clinical, or administrative duties that I perform at any institution with the exception of activities performed as an outside consultant. In addition, I certify that there is no possibility of dual compensation for the same work.

Print Investigator Name/Signature

Date

INVESTIGATORS, PLEASE CHECK:

MOU submitted with grant application MOU submitted as result of award MOU submitted due to change in effort

Print VA Department Chair Name/Signature

Date

Terence M. Keane, PhD VA ACOS for R & D

Date

Michael E. Charness, MD VA Chief of Staff

Date Annual June MOU deadline

Print BUMC Department Chair Name/Signature

Date

Print Assistant Vice President for Sponsored Programs Name/Signature

Date

Print Authorized Official Name/Signature Other Affiliated Institution

Date

All salaried BUMC investigators holding salaried VA appointments must complete a Memorandum of Understanding (MOU) at least annually, in June of each year. In addition, investigators must submit an MOU with each new and non-competing application; with each new award; and when significant changes in effort occur. The VA Associate Chief of Staff and the BU Assistant Vice President for Sponsored Programs are responsible for MOU oversight and record-keeping. To complete form: Insert requested information into appropriate box. For rank, use INST (Instructor): ASTP (Assistant Professor); ASCP (Associate Professor); PROF (Professor). Estimate the number of hours worked per week in each type of activity for each affiliation. Enter the hours only--the spreadsheet calculates the percent. Use a 60-hour week as basis. Reminder: for K awards, the percent of BUMC research effort must be at least 75% and all of it must be paid, may not include effort donated or paid by another party. Please supply complete agency grant/contract number(s) on the lines provided. If you need more space, write-in additional information. Form and instructions are available on the Forms and Worksheets page of the OSP site.
Questions: Kirsten Levy, M.B.A., BUMC/VABHS Program Manager, klevy@bu.edu, 857-364-5682 Terence M. Keane, Ph.D., Associate Chief of Staff for Research, VABHS, 857-364-4551

MOUrev.xls

7/2011