Stipend Card User Account Request Form

I am requesting a stipend card for someone other than myself.

Requestor Name *

New User Information

First Name *

Last Name *

Email Address *

Department

CHS Employee Position

User Role:

ApproverStudy Coordinator

Study Name(s) to Associate User To:

ClinCard Attestation

I attest that I have reviewed, understand, and agree to comply with the OSU-CHS Policy Administration and Utilization of ClinCard System.pdf and financial requirements governing participant payments, including applicable federal regulations and sponsor requirements. *

YesNo

If serving as a Requestor:

I acknowledge my responsibility to initiate transactions in compliance with policy and to ensure all payments include required supporting documentation and justification.

If serving as an Approver:

I acknowledge that I am responsible for the independent review and approval of participant payments and must ensure such payments comply with protocol requirements, approved budgets, and all applicable standards. I understand that my approval signifies oversight, verification, and accountability for each transaction.

If serving as a Principal Investigator (PI):

I acknowledge my role as Principal Investigator and accept ultimate responsibility and accountability for all ClinCard transactions conducted under my project, regardless of delegation. I confirm that appropriate oversight, training, and monitoring of study personnel are in place. I understand that transactions not meeting compliance criteria will be rejected. If funds have already been disbursed for non-compliant transactions, I acknowledge that such charges will be transferred to non-sponsored funds, with financial responsibility borne by my department.

Signature (draw signature with mouse or finger) *

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