XI. Outside Consultation

Any remuneration you received from the State of Texas and/or Federal Government institutions or agencies during the fiscal year, must be reported to the Dental Branch and the Health Science Center. An official request for this information will come from the Dean’s Office in September of each academic year. The attached form will also be sent to you.
THE UNIVERSITY OF TEXAS HOUSTON HEALTH SCIENCE CENTER at HOUSTON
REPORT ON OUTSIDE REMUNERATION FROM STATE AND FEDERAL AGENCIES
SEPTEMBER 1, 2000 THROUGH AUGUST 31, 2001

 

Name:                                                                    (Include credentials, M.D., D.D.S., Ph.D., etc.)

Signature:                                                                              Date:                  

Department:                                                                                                     

Pursuant to Part One, Chapter III, Section 13, of the Regents’ Rules and Regulations, list all reimbursements (including travel), salary, bonuses, honoraria, and consultation fees received from other State of Texas and Federal institutions and agencies from funds not on deposit with UTHHSC, during the 2000-2001 fiscal year.

Please give a written explanation of all individual amounts over $10,000. Please type or print legibly.

FEDERAL AGENCY/INSTITUTION

 

 

 

 

STATE OF TEXAS AGENCY/INSTITUTION

  

DATE

 

 

 

 

DATE

 AMOUNT

 

 

 

 

         AMOUNT

  *PURPOSE

 

 

 

 

         *PURPOSE

 

                          

 

 

*Salary, bonuses, travel reimbursement, honoraria, consultant fees, etc.