Chair CommitmentReimbursement Requests

Chair Commitment

Reimbursement Requests

Please submit one Chair's Commitment request per form (#3 below).

If you have any questions, reach out to Daisy Cazares (DCazares@mednet.ucla.edu).

For more information:

https://medschool.ucla.edu/sites/g/files/oketem456/files/media/documents/_DOMORA_Manual_Post-Award_Chair-Commitment-Format.pdf

Requester Name*

Requester Email*

1. Divison*

e.g. Cardiology

Select

2. Faculty Name*

e.g. Dr. Joseph Bruin

3. Description of Chair's Commitment*

e.g. Start-up

4. Time Period for Expenses Incurred*

If requesting for multiple quarters, check all applicable quarters.

Q1-Summer: July - September 2024

Q2-Fall: October - December 2024

Q3-Winter: January - March 2025

Q4-Spring: April - June 2025

5. Total $ Amount of Request*

e.g. $2,348.03

6. Full Accounting Unit (FAU) to Reimburse*

e.g. 401357-JB-62246. Can include sub, project and source code, if needed.

7. Backup Documents*

Upload both payroll & non-payroll expense backup, as applicable, in a single Excel workbook. e.g. Detail Closed & Employee Sum. You may also upload any additional back-up documents such as (extension approval, letters, etc.)

Excel file naming convention:

Department Code_PI Last Name_Fiscal Year_Quarter_Mmm-MmmYY_$ Amount

e.g. 1553_Bruin_FY21-22_Q1_Jul-Sep21_$15,149.93

Drag and drop files here or

8. Comments

Add any additional comments, if needed.

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