Attachment

16. Identify all cash, stipends, 77% s~*c!ont~ fen sihlin Herne eaienbuenawnante--ennale lodging, transportation, entertainment, free attend_..-_, -. 2.2. --.. ee nn gee eee pee eee ~~-sonally to the employee and/or members of the employee's family to be received at or in conjunction with the award event. Indicate the market value of each item. Employee Family [[] Cash/stipend/cash equivalent $ 900000 ¢ N/A Oo Award medallion, trophy, sculpture, or other tangible memento of the $ 1400 $ N/A occasion which has utility and/or artistic merit and a commercial value in excess of $20 Oo Awards ceremony dinner, reception, and/or entertainment (indicate number of $ 0 $ family members attending: 9 ) [[] Travel expenses for meals, lodging, and/or transportation provided in-kind or $ $ through cost reimbursement Will sponsored travelbe used? [[] Yes [2] No (If yes, annotate your sponsored travel that it is for an award.) [-] Other items or benefits provided, e.g., journal subscription, organizational $ $ membership. Describe: Totals* $ $ 901400 - [-]NIH Ethics Advisory Committee (NEAC) jurisdiction: If the aggregate value of gifts for you and your family/guest is $2500 or more, excluding official government travel (sponsored travel), the award must be,reviewed by the NEAC. Travel expenses accepted personally by the employee (not sponsored travel) _ must be included in the aggregate value. Attach a copy of the letter or electronic mail indicating that you are the intended recipient of the award. 17. EMPLOYEE'S STATEMENTS AND SIGNATURE: A. I have read the attached notices. I request permission to accept the award honor and the associated gifts as described above. B. Disqualification Requirement: I understand that I am recused (disqualified) immediately from all official matters involving or that could affect the award donor. If the award is approved, my recusal from matters involving the donor remains in effect for one year following the date I receive the award and I will not participate in any official matters involving the award donor organization without prios authorization from my Deputy Ethics Counselor. Sign & Date: Anthony FAUCI 02/01/2021 18. SUPERVISOR'S STATEMENT AND RECOMMENDATION: (Omit for IC Directors) The employee has no recent, current, or pending official matters with or that can affect the outside organization or a majority of its members (5 C.F.R. § 5501.111). If the award is approved. I will accept responsibility for all official matters from which the employee is recused due to the receipt of this award. [-] Recommend Approval [-] Do Not Recommend Approval Sign & Date: Lawrence TABAK 03/19/2021 19. INTERMEDIATE REVIEWER (IC DEC signs here for NEAC jurisdiction or NIH Senior employee) Based on my review of the foregoing statements and supporting documentation in light of the requirements of 5 C.F.R. § 2635.204(d), I: [-] Recommend Approval [-] Recommend Approval with the Following Conditions: F-] Do Not Recommend Approval Sign & Date: 20. DEPUTY ETHICS COUNSELOR (OR DESIGNEE) Based on my review of the foregoing statements and supporting documentation supplied by the employee, this constitutes my (written, when required) determination, pursuant to 5 C.F.R. § 2635.204(d), that the employee's request is: CO Approved as Requested C Approved with the Following Conditions: [-] Disapproved Sign & Date: NIH- 2854 (Rev 08/09)