Northwestern University

Memorandum of Understanding

For Individuals with Joint University/NMFF/Veteran’s Affairs Medical Center Appointments

Investigator Name: ______

Effective Date: ______

This document describes the total professional responsibilities mutually arranged by Northwestern University [hereafter referred to as “the University”], the Northwestern Medical Faculty Foundation [“NMFF”] (if applicable), and (select one)

___ the VA Chicago Health Care System

___ other VA Medical Center (provide name) ______

[hereafter referred to as “the VA Medical Center” or “VA”]

The combination of teaching, research, administration, public service, and clinical activities at the University, NMFF (if applicable) and the VA Medical Center comprise 100% of the total professional responsibilities, encompassed by the individual’s appointments at these institutions, as follows:

VA / University/NMFF
Title / [insert VA title] / [insert University faculty title] / Total

Total effort dedicated to:

Teaching, university administration, service / (E) __ % / __ %

Sponsored research

/ (C) __ % / (F) __ % / __ %

Clinical activities

/ (D) __ % / (G) __% / __ %
Total / (A) __ % / (B) __ % / 100%
Appointment = ___/8ths
VA hours/week = ____ / (# of 8ths * 40 hours/week)

See Instructions for details on calculating (A) through (G)

__ If the individual has an NIH “K” award, please indicate here. Contact OSR for special instructions on completing this form appropriately.

__ If the individual has other professional appointments (e.g., Cook County Hospital, Children’s Memorial Hospital), please indicate here.

I certify that this individual has joint appointments at Northwestern University, the Northwestern Medical Faculty Foundation (if applicable), and the VA Medical Center and receives salary from each entity. I also certify that there is no possibility of duplicate compensation for the same work, nor is there an actual or apparent conflict of interest.

______

Investigator VA R&D

______

University/NMFF Department Chair VA Chief of Staff

______

Dean NU Feinberg School of Medicine VA Director

Last Revised: 7/22/04