Manual Exhibit 5

Click this link http://www.ihs.gov/NonMedicalPrograms/pies/pdf/hhs348.pdf for a copy of the actual form, below is a sample of what the form looks like.

REQUEST FOR APPROVAL TO ACCEPT PAYMENT OF TRAVEL EXPENSES
FROM A NON-FEDERAL SOURCE_______________
(date)

Use this form to Request, approve, and report acceptance as provided in DHHS Travel Manual Chapter 1-70. Submit this request to the recommending official as soon as possible, but NO LATER THAN 15 DAYS BEFORE scheduled departure.

1.	Name and Title of Traveler	2.	Name and Address of Sponsoring Organization (including telephone number and fax number):
3.	Traveler's Organization
4.	Purpose of Trip:
5.	Payment to be made for:	____Travel	____Subsistence
	Authority for Travel: (See DHHS Travel Manual Chapter 1-70)	____31 USC 1353	____42 USC 3506	____5 USC 7342
	Method of Payment:
	A____ Direct Reimbursement to Appropriation____Appropriation No.____ B____In Kind C____In Cash for retention by Traveler (Note: Cash may only be accepted under 42 USC 3506 Authority)		$____ $____ $____	Indicate Value of Payment Travel $____ Lodgings $____ Meals $____ Other $____
6.	Payment to be used for Travel:		____Round Trip	____One Way (See itinerary below)

Starting Date	Ending Date	From	To

7.	Is the Department paying part of the Travel Cost? (If any, specify)
8.	Recommendation (See Reverse side of this form)
9.	Authorization:
	Authorizing Official name_______________	Title______________	Date_________
10.	Traveler's Certification (Complete after trip) I certify that while on official travel the above amounts are correct and I did not receive (1) any honoraria, or (2) any cash for my retention from the sponsoring organization. I further understand that any accommodations, meals, or incidental expenses accepted that are not normally reimbursed by Government Travel Regulations, and not fully reimbursed by the sponsoring organization will be borne out of my personal funds. Traveler's Signature_______________________ Title____________ Date______

BACKGROUND INFORMATION ON REQUEST FOR APPROVAL
TO ACCEPT PAYMENT OF TRAVEL EXPENSES FROM A NON-FEDERAL SOURCE

Traveler:_______________________________________

1.	Is the sponsoring organization using Federal funds to defray the costs of this trip? *(If yes, reimbursement may NOT be accepted.)* Yes_______ No_______
2.	Is the letter of Invitation attached? The Letter of Invitation must outline, in detail, the types of expenses offered and the amount of the expenses? *(Requests without a Letter of Invitation will NOT be considered for approval.)* Yes_______ No_______
3.	Is the traveler an officer, director, trustee, partner or an employee of the sponsoring organization? (Please attach a copy of an approved HHS-520, request for Approval of Outside Activity.) Yes_______ No_______
4.	Are there any circumstances under which the acceptance of expenses in this instance would create a conflict or the appearance of a conflict of Interest? Yes_______ No_______
5.	Is the sponsoring organization offering to pay amounts which are in excess of those ordinarily allowed by applicable Federal Travel Regulations? (For example - amounts in excess of the maximum Per Diem rate and/or the mode of transportation is above coach.) Yes_______ No_______
6.	Is this request for acceptance of payment for an accompanying spouse of a DHHS employee? *(If yes, employee's Travel Order must be included.)* Yes_______ No_______
7.	How does this trip meet the Department's priorities and goals?
8.	Why can't this trip be paid for with DHHS funds?
	I hereby certify that the acceptance of this request with policies in Chapter 1-70 of the DHHS Travel Manual. To the best of my knowledge, I also certify that Federal Grant or Contract funds are not being used to defray, in whole or in part, the expenses of this request. Therefore, I recommend approval of this request as being in the best interest of the Government.
_____________________________________ _______________________ ________________ Recommending Official Title Date _____________________________________ _______________________ ________________ Recommending Official Title Date

INSTRUCTIONS FOR COMPLETING THE HHS-348 FORM

The Department of Health and Human Services (HHS)-348 form is found at:

http://www.ihs.gov/NonMedicalPrograms/pies/pdf/hhs348.pdf

The appropriate Area Office RECOMMENDING OFFICIAL MUST SIGN the second page before submission to the Director, Program Integrity and Ethics Staff (PIES).

INSTRUCTIONS: Side One of HHS-348

Item 1.	State the traveler’s complete name and position title.
Item 2.	State the non-Federal source’s complete name, contact person, address, phone and fax numbers.
Item 3.	State the traveler's organization information: Area/Service Unit/Facility
Item 4.	State the purpose of the travel and the relationship between the traveler’s official duties and the proposed activities and travel.
Item 5.	Indicate with an "X" whether the payment is to be for travel and/or subsistence. Authority for Travel: Here you choose one of the three authorities. In most cases, 31 U.S.C. 1353 is the authority used by HHS staff. If unknown, leave blank, and PIES will complete entry. Method of Payment: Indicate by marking an "X" on the lone behind "A,""B," or "C." (Item C is rarely used.) Indicate Value of Payment: Obtain the estimated dollar amounts for each category from the non-Federal source. Indicate "O" for each category the non-Federal source will not be found. Note: Estimates can be used until the trip is actually completed and certified by the traveler.
Item 6.	State the traveler’s complete travel itinerary. Indicate round-trip or one-way trip, expected start and end dates, and travel locations.
Item 7.	State the amount to be paid by the HHS/IHS.
Item 8.	Leave this part blank .
Item 9.	Leave the authorizing official name line blank (for the Deputy Ethics Counselor’s signature), type “Deputy Ethics Counselor” on the title line, and leave the date line blank.
Item 10.	This part must be completed, signed, and dated by the traveler after completion of the authorized travel. The Traveler must certify all actual costs. In item 5, “Indicate Value of Payment,” the traveler can make ink pen changes and initial. Note: These certified costs will be used for reporting requirements. The traveler must complete this certification and return it to PIES within 10 calendar days of the completion of travel. Failure to complete this certification can affect all future requests for HHS-348 approval.

INSTRUCTIONS: Side Two of HHS-348

Part 1	Indicate X for applicable response.
Part 2	Indicate X for applicable response.
Part 3	Indicate X for applicable response.
Part 4	Indicate X for applicable response.
Part 5	Indicate X for applicable response.
Part 6	Indicate X for applicable response.
Part 7	Provide a concise statement on how this trip will meet HHS priorities and goals.
Part 8	Provide a concise, specific justification for why HHS funds are not being used to support this trip.