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?
Existing 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, you will receive a instant confirmation of your membership status.

Please note, memberhip status will be reviewed as part of the voucher approval process and all ineligible requests will be denied!
- Please specify the intended use of the voucher?
  
  Other
- Please select the ACTRI service(s) for which you are requesting a voucher:
- 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 TRH Lab services has been reached for this voucher period. You may submit your TRH 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!
- Study/Project Title:
- IRB # (if available):
  Example: 129738 (6 digits only)
- Please upload a brief Project Outline, Study Abstract or Research Protocol
  
  Browse Files
  
  Cancelof
- Have you already submitted an ACTRI service request for which you would like to use this voucher?
- Please enter a valid Service Request ID below to help us match your voucher application with your existing service request. Voucher applications containing invalid Service Request IDs will be rejected!
- Service Request ID:
  Example: JF-CLR-###### / JF-CCBB-###### / etc.
- We no longer accept voucher applications without prior service request submissions. If you haven't done so already, please submit your ACTRI service request first, and then return to this form to request a voucher!
- Have you already submitted a voucher request for this specific study/project during the current voucher period (5/1 - 4/30), which has been approved?
- Per ACTRI voucher policy, only one voucher application is permitted per PI and study/project per voucher period.
- PI First Name
- PI Last Name
- PI Full Name
- PI Email
  example@health.ucsd.edu
- PI Department
- Voucher Requestor same as PI?
- 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:
  
  Other
- Industry-sponsored studies are not eligible to receive voucher support. Please review the ACTRI voucher eligibility criteria for additional details.
- Organizational Affiliation:
  
  Other
- Any further information or comments you would like to submit with this request:
- Confirmation:
- For any additional voucher-related questions, please contact ctri-fin-recharges@health.ucsd.edu prior to submitting your request!
- Submission Date
  
  YearMonthDay
  DateHourMinutesAM/PM Option
- RC_BMI
- RC_BST
- RC_Clinic
- RC_CRC
- RC_CTSS
- RC_TRT
- RC_CCBB
- RC_DAC
- RC_DISC
- Request Contains VOU (transfer only)
- BMI Short Name
  "Bioinformatics" or "Suspended"
- BMI Voucher Amount
- BST Short Name
  "Biostatistics" or "Suspended"
- BST Voucher Amount
- Clinic Short Name
  "Clinic" or "Suspended"
- Clinic Voucher Amount
- Coord Short Name
  "Coordinator" or "Suspended"
- Coord Voucher Amount
- CTSS Short Name
  "CTSS" or "Suspended"
- CTSS Voucher Amount
- TRT Short Name
  "TRH Lab" or "Suspended"
- TRT Voucher Amount
- CCBB Short Name
  "CCBB" or "Suspended"
- CCBB Voucher Amount
- DAC Short Name
  "DAC" or "Suspended"
- DAC Voucher Amount
- DISC Short Name
  "DISC" or "Suspended"
- DISC Voucher Amount
- Should be Empty: