1 Start 2 Complete Page 1 of 2 This form is intended to assist the Office of Research Administration with your departure from the University of Arizona. Please continue working with your department administrator and HR department to ensure all necessary licensing, insurance, and other HR/department related needs are taken care of. The details submitted within this form will be kept confidential and will only be shared with the UAHS Office of Research Administration. You may save a draft of this form when logged in through your UA NetID. UA Department Name * Departing PI Name * First Name and Last Name Departing PI Contact Information * Earliest Anticipated Departure Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Does this PI have any active grant accounts at the UA? * - Select -YesNoNot Sure Do you have any open IRB protocols? * - Select -YesNoNot Sure Please List Open IRB Protocol Numbers Do you have any open IACUC protocols? * - Select -YesNoNot Sure Please List Open IACUC Protocol Numbers Have arrangements been made for appropriate disposition of any animal care or stored specimen repositories? - None -YesNoNot Applicable Do you have any assets you wish to transfer to an outside Institution? * - Select -YesNoNot Sure i.e. centrifuges, freezers, computers, furniture. Please List UA Assets you wish to Transfer Do you wish to relocate any of the following: Research Data, Blood Products, Tissues, Drugs, and/or Devices? * - Select -YesNoNot Sure Please List a description of the Research Data, Blood Products, Tissues, Drugs, and/or Devices * Do you have any Chemical, Reagent, and Radioactive Materials to dispose of and/or transfer? * - Select -YesNoNot Sure Please Contact the Office of Radiation, Chemical, and Biological Safety (http://orcbs.arizona.edu) Have you notified your Departmental Administrator/Chair of this departure? * - Select -YesNo Do you have any cash advances, petty cash accounts, pending reimbursements, or operational advances open at the UA? * - Select -YesNoNot Sure Have you notified your UA Employees of their termination date? * - Select -YesNoNot Applicable Please Contact your Departmental Representative Do you have teaching requirements which will be impacted by this departure? * - Select -YesNoNot Applicable Departmental Contact Name Please provide a departmental contact that our office may speak to about this PI's transfer. If not sure, leave blank. Departmental Contact Information Please provide a phone number or email address for the individual most appropriate to contact in your department regarding this transfer, if available. Any other information we should know? Please provide a description of any extenuating or unique circumstances surrounding this PI's departure Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
