Manual Exhibit 5-22.3-A

INDIAN HEALTH SERVICE
GIFT PRE-ACCEPTANCE CHECKLIST
(This is not an exact replica of the Checklist)

INDIAN HEALTH SERVICE (Organization)

 Date:
Name of Employee Receiving Offer:
Person to Contact in Receiving Office:
Telephone:                                  FAX:                               E-mail Address:

Monetary/Non-monetary

 Conditional/Unconditional
Name of Donor:
Donor's Address:
Street:
City:                       State:           Zip code:
Telephone:		 Point of Contact:



E-mail Address:
Description and/or Purpose of Gift:

 
Donor imposed restrictions and/or conditions:

 
Recommendations:
Acceptance:           ______________
Non-acceptance:    ______________
 
Reason(s) for Non-acceptance:


Comments:

 
Concurrence/Non-concurrence (circle one)

 
Executive Officer - Signature                                                                       Date
Concurrence/Non-concurrence (circle one)

 
Authorizing Official - Signature                                                                     Date