Dell Medical School Outside Activity Disclosure Approval Portal

Use this Portal to Disclose Outside Activities and Equity Interests

Clinician’s Interactions with Industry Policy

Click here to access the policy: https://utexas.app.box.com/file/632188869928?s=45yfymxuddtyidyeyicysu7003xznvwz

Discloser Name (First, Last)*

Discloser Email*

Date of Submission*

What Type of Outside Activity are you Disclosing?*

Select

Are you a Member of the MSRDP?*

Select

Are you a Clinician?*

Select

Outside Entity Information

Complete this section for each entry

What is the name of the Entity or Organization?*

Entity Address*

What type of Entity or Organization?*

Select

If Other, please describe:

Duties for the Outside Entity

Describe the Duties you will perform for the Outside Entity:*

Are these duties related to your institutional responsibilities?*

Select

Do these duties include patient care, patient case review, expert services, or court appearances?*

Select

If you are a clinician, does the outside activity comply with the Clinicians Interactions With Industry policy?

Please find the policy referenced at the through the following link: https://utexas.app.box.com/file/632188869928?s=45yfymxuddtyidyeyicysu7003xznvwz

Select

Time for Outside Activity

Planned Start Date for the Outside Activity*

Planned Finish Date for the Outside Activity*

Estimated Number of Hours of Service:*

Time Frequency*

Select or enter value

Will the Outside Activities be performed outside your normal Dell Med working hours or leave be taken for any activities occurring during normal working hours?*

Select

Any Additional Comments relating to the time for this Activity:

Compensation for Outside Activity

What is the total amount of compensation you will receive from the outside activity?*

What types of compensation will you receive?*

If you select only equity interest please complete the remainder of this section and move to the end of the form to submit. If you need to select more than one option please select "Other" and list all options in the next field.

Select

If other compensation, please describe:

If you are receiving equity in an outside entity, what is the percentage of the fully diluted equity value at time the equity is granted?

Travel/Expense Reimbursement

Will the outside activity include travel or expense requiring reimbursement?*

Select

If yes, to Question #18, are these expenses separated from the outside compensation in your agreement with the outside entity?

Select

Dell Medical School Supervisor

Who is your direct supervisor at Dell Medical School?*

Supervisor's Email Address:*

Has your Dell Medical School Supervisor approved the outside activity?*

Select

File Attachments

Please attach any agreement or any other documents you would like reviewed.

Drag and drop files here or

Send me a copy of my responses

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