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U.S. Department of Health and Human Services

Inspections, Compliance, Enforcement, and Criminal Investigations

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Inspections

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ATTACHMENT F

ATTACHMENT F

 

Office of Financial Management

 

SPONSOR CERTIFICATION

 

The Food and Drug Administration requires the following information to be completed by sponsoring organizations requesting FDA employees to attend, participate in, or speak at non-federal meetings, conferences, and symposiums.

 

NAME OF SPONSOR ISSUING INVITATION:__________________________________________________

____________________________________________

SPONSOR MISSION STATEMENT: ___________________________________________________________

___________________________________________________________

__________________________________________________________

___________________________________________________________

TARGET AUDIENCE: ______________________________________________________________

______________________________________________________________

PURPOSE FOR WHICH THE FDA EMPLOYEE IS BEING INVITED: ______________________________

_____________________________________________________________

_____________________________________________________________

NAME OF FDA EMPLOYEE: ________________________________________________________________

NATURE OF COSTS TO BE REIMBURSED TO FDA (i.e., airfare, lodging, meals. miscellaneous expenses): __________________________________________________________

Additional Certification:

Yes ___ No___ Is the traveler an officer, director, trustee, board member, partner or an employee of the sponsoring organization?

Yes ___ No___ Does the traveler’s Center/Office have a contract or grant with the sponsoring organization?

Yes ___ No___ Is the sponsor (or a component of this sponsoring organization) a party to a matter, which is pending before the FDA?

Yes ___ No___ Is the sponsor a for-profit organization?

Yes ___ No___ Does the sponsor engage in any lobbying activities?

Yes ___ No___ Does the sponsor include corporate as well as individual membership? if so, how many and what is the percentage of corporate members?

WE ALSO AGREE TO THE FOLLOWING:

None of the funds that will be used to support these travel costs come from any federal grants or from any contracts with the Department of Health and Human Services, or from the regulated industry or trade associations.

We also understand that FDA requires that its employees pay directly for all of their travel costs and that we will be billed for these costs by FDA after the trip has been completed and the traveler’s claim has been submitted to FDA. We further understand FDA’s requirements that costs of employee travel accommodations may not be subsidized in any way, and assure that we will comply with that policy.

Any room charges that are arranged for FDA employees by our organization will not be less than the hotel would normally charge to the traveling public, with the sole exception of volume discounts made available to us by the hotel. Our organization will not otherwise arrange for or make any additional payments to the hotel to defray room costs for FDA employees.

Name: (Please Print)___________________________________

Title: ______________________________________

 

Signature:__________________________________ Date: ____________________

 

Budget Formulation - Budget Execution - Financial Systems – Applications – Accounting – Travel - Payroll

5600 Fishers Lane, Rockville, MD 20857, HFA-100, 301-827-5001

2 of 2       7/3/01 1

FMD 13

 

 

Distribution: Regional Food and Drug Directors and District Directors
  FDA Headquarters Offices
Issued by: ORA/ORO/Division of Field Investigations (HFC-130)
Authority: ORA
Publication Date: November 2002

This page was last updated on: 02/20/2003.

 
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