Stanford Medicine Industry Interactions Policy (SMIIP) Intake Form

Please complete this form and a decision regarding your request will be sent to you shortly.

Name*

Email*

Department or Institute*

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What is your inquiry?*

Who else has been consulted on this inquiry?

What section of the SMIIP relates to this inquiry?

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Are money and/or other items of value connected to this inquiry? If so, please quantify the amount and how they would be transferred?

Do you have any concerns regarding this inquiry? If so, please describe.

Is there a precedent for this activity at Stanford Medicine or at another Academic Medical Center?

What is the timeframe and/or urgency of this inquiry?

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