# Appendix 1: Gift Acceptance Description Form and Validity Test Survey

## Section A: Gift Acceptance Description Form

IC: Date:

IC Point of Contact (Name):

Telephone:

Fax:

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**Please Print:**

Name of Donor:

Donor's Address:

Street:

City:

State:

Zip Code:

Donor Point of Contact (Name):

Telephone:

Fax:

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Category of Gift:

Check applicable box: Monetary Nonmonetary

> Conditional Unconditional

Personal Property Real Property

Amount/value of gift: \_\_\_\_\_\_\_\_\_

Description and purpose of gift including any donor imposed restrictions
or conditions:

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## Section B: Validity Test Survey

This survey will help to determine whether NIH is in compliance with the
statutory and delegated authorities to accept gifts from the private
sector, conditional and unconditional, monetary and nonmonetary, and
whether there may be any potential for a conflict of interest.

1.  Will acceptance of the gift, to a reasonable person, compromise the
    integrity of, or the appearance of the integrity of a Governmental
    program or of any official involved in that

> program? \*
>
> Yes \_\_\_\_\_ No \_\_\_\_\_\_

2.  Is there an actual or apparent conflict of interest?

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

3.  Is there any matter pending before the NIH that would affect the
    interest of the donor, e.g., approval of a grant or award of a
    contract? If so, what? Indicate the nature of the matter.

> Yes \_\_\_\_\_\_ No \_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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4\. Does the NIH control activity in which the donors have an interest
or the potential for an interest, such as CRADAs, research and
development or other contract programs, grant programs, or clinical
trials? If so, indicate which activities.

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

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5.  Will the amount/value, or the nature of the gift alone raise a
    significant concern?

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

6.  Is the gift being offered for endorsement purposes?

> Yes \_\_\_\_\_\_ No \_\_\_\_\_\_\_

7.  Does the gift meet generally acceptable public standards?

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

8.  Is the gift reasonable to administer?

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

9.  Will the principal beneficiary of the gift be the NIH?

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

10. Are there donor imposed restrictions or conditions?

> Yes \_\_\_\_\_\_ No \_\_\_\_\_\_\_

11. Is the gift being offered to the NIH to support the activities of a
    specific individual employee?

> Yes \_\_\_\_\_ No \_\_\_\_\_\_

12. What is the practical impact of the gift within the NIH or IC?

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\* NOTE: If the gift is from a determined "prohibited source" as defined
in Section E.1. of this manual chapter, please ensure that you follow
the applicable procedures outlined in that section.

If your answer was "Yes" to Question Nos. 1 - 6; or "No" to Question
Nos. 7 -- 9, careful scrutiny should be given to any unfavorable
responses and the Office of the General Counsel should be consulted for
advice.

**[Signatures:]{.underline}**

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IC Recommending Official Date

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IC Ethics Official Date

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IC Authorizing Official (See NIH Date

Manual 1130, Finance No. 5)