ACTRI Service Voucher Request Form

ACTRI Service Voucher Request Form
The ACTRI voucher capacity has been reached for this voucher period. You may submit your request after the new voucher period begins on May 1, 2021.
Voucher Deadline Approaching: All new and existing vouchers will expire on 4/30/21. If you require continued voucher support beyond 4/30/21, you will have to submit a new application on or after 5/1/21. Voucher balances are not carried forward from one voucher period to the next!
Please review the ACTRI voucher eligibility criteria and available support levels prior to submitting a request!
Is the requesting PI an ACTRI General or Associate member?

Yes, existing General or Associate member.Pending, applied for General or Associate membership.No / Don't know.
Existing or pending General or Associate memberhip is required to qualify for an ACTRI voucher. Please click here to review membership eligibility criteria and submit your application. Once submitted, please select 'Pending' from the above options to proceed.

Please note, memberhip status will be reviewed as part of the voucher approval process and all ineligible requests will be denied!

- Eligibility Pass
Please select the ACTRI service(s) for which you are requesting a voucher:

Biomedical Informatics (BMI) [details]Biostatistics [details]Use of Clinic [details]Coordinators [details]Clinical Trial Support Services [details]TRT Laboratory (not Clinic) [details]Center for Computational Biology and Bioinformatics (CCBB) [details]DAC (only select if instructed to do so by DAC PM)Dissemination and Implementation Science Center (DISC) [details]
The ACTRI voucher capacity for BMI services has been reached for this voucher period. You may submit your BMI request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for Biostatistics services has been reached for this voucher period. You may submit your Biostatistics request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for Clinic services has been reached for this voucher period. You may submit your Clinic request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for Coordinator services has been reached for this voucher period. You may submit your Coordinator request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for CTSS services has been reached for this voucher period. You may submit your Coordinator request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for TRT Lab services has been reached for this voucher period. You may submit your TRT Lab request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for CCBB services has been reached for this voucher period. You may submit your CCBB request after the new voucher period begins on May 1st!
The ACTRI voucher capacity for DISC services has been reached for this voucher period. You may submit your CCBB request after the new voucher period begins on May 1st!

- Service Request Pass
PI First Name*
PI Last Name*
PI Full Name
PI Email*
example@health.ucsd.edu
PI Department*
Voucher Requestor same as PI?

Yes
Requestor Name*

First NameLast Name
Requestor Email*
example@health.ucsd.edu
Requestor Department*
Valid Chart String Required

Please provide valid chart string information, which will only be used in the event that the services rendered exceed the applicable voucher amount. Click here to review current ACTRI recharge rates.

If you are unsure about your correct chart string, please contact your fund manager to clarify prior to submitting your request!
Fund Manager Name*

First NameLast Name
Fund Manager Email*
example@health.ucsd.edu
OFC Project:*
Always required! (7 digit numerical value)
OFC Task:*
Always required! (1-3 digit numerical value)
OFC Funding Source:
Required for sponsored projects only! (5-7 character alphanumerical value)
Award #:
Justification:
Funding Agency:*

NIH or other federal support with study section reviewIndustry Sponsored StudyCTRI Pilot Project AwardCTRI KL2 AwardCTRI TL1 AwardFoundation SupportInvestigator-initiated without NIH or other federal study section reviewOther
Industry-sponsored studies are not eligible to receive voucher support. Please review the ACTRI voucher eligibility criteria for additional details.