Please address and acknowledge the following criteria:

a.      CW will have no supervisory, fiscal, managerial or oversight responsibilities
b.      CW will not be in a training position
c.      CW's duties will include (please provide list and indicate hard-to-find services/functions with an asterisk*)
d.      CWs will not initiate research or perform patient care that involves making a final diagnosis
e. CW appointment will be short-term (one year at a time) and limited to the contract's5 year period

 By signing, I certify that statements a to e above are correct and the additional information requested has been provided.

Name _______________________ Signature ________________________ Date ____________

Sponsoring Principal Investigator

Please attach CV and bibliography.

EXCEPTION REQUIRING DDIR APPROVAL:

Appointment of more than one Staff Scientist or Specialist (CW) per Principal Investigator (please see content of memo at http://www1.od.nih.gov/oir/sourcebook/prof-desig/appt-stsci.htm

IC Approval by SD: ______________________
Date approved: ______________________

Hard copy to DDIR (Bldg. 1 - Room 140) on: ____________________

Or email to Dierdre Andrews (andrewsd@od.nih.gov) AND Dr. Arlyn Garcia-Perez (garciaa@od.nih.gov)

DDIR Approval (if necessary): ____________________________      Date:  _______________

If this involves a foreign national with a visa, please send a copy of this checksheet to the Division of International Services, Bldg 13 - Room 2W48.