Qualtrics Survey | Qualtrics Experience Management

Remuneration for travel must be disclosed within 30 days of returning from each trip. Travel disclosure is not required when the travel is reimbursed or sponsored by the following:

A federal, state or local government agency located in the USA;
An institution of higher education located in the USA;
An academic teaching hospital located in the USA; or
A research institute located in the USA that is affiliated with an institution of higher education located in the USA.

Please note, compensation such as honoraria, consulting fees, etc. are to be disclosed in the COI Disclosure Form.

First Name

Last Name

Email

Are you a CU Denver | Anschutz Medical Campus employee?

Yes
No

CU Employee ID

Purpose of the Trip

Sponsor or Organizer

Destination City

Destination State

Destination Country

Duration of the trip (in days)

Departure Date (format as mm/dd/yyyy)

Return Date (format as mm/dd/yyyy)

Estimated value of the trip (in US dollars)

Comments

Do you need to send a copy of this form to someone else?

Yes
No

Additional email address needing to receive a copy