Sheet 1: Certify Effort Form

	
	
	
	
	
	
	
	
	
	

		
University of Pennsylvania
		
	

		
Certify Effort Form
		
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
Reporting Period
		


		


		


		


		


		
Year
		


		


		


		


		


	
	

		

 
		
		


		

 
		
		


		


		


		


	
	

		


		


		


		


		


	
	

		
Name:
		


		


		


		
Employee ID:
		


		


		


	
	

		
SubDept.
		


		


		


		
Division:
		


		


		


	
	

		
Accounts
		


		


		


		


		


		


		
Description
		


		
Payroll %
		
Cost Sharing %
		
Certified Effort %
	
	

		
Sponsored Accounts
		


		


		


		


		


		


		


		


		


		


		


	
	

		
CNAC
		
ORG
		
B/C
		
FUND
		
OBJ
		
PGM
		
CREF
		


		


		
 
		
 
		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		
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.
	
	

		


		


		


		


		


		


		


		
Total Sponsored Accounts
		


		
0.0%
		
0.0%
		
0.0%
	
	

		


		


		


		


		


		


		


		
Description
		


		
Payroll %
		
Cost Sharing %
		
Certified Effort %
	
	

		
Non-Sponsored Accounts
		


		


		


		


		


		


		


		


		


		


		


	
	

		
CNAC
		
ORG
		
B/C
		
FUND
		
OBJ
		
PGM
		
CREF
		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		
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Total Non-Sponsored Accounts
		


		
0.0%
		
0.0%
		
0.0%
	
	

		


		


		


		


		


		


		


		
GRAND TOTAL
		


		
0.0%
		
0.0%
		
0.0%
	
	

		
This section must be completed by UPHS Clinical faculty paid from a CPUP Interfund account.  
		


		


		


		


		


		


		


		


		


		


		


	
	

		
Please indicate the appropriate % effort for the following section.
		


		


		


		


		


		


		


		


		


		


		


	
	

		
For an explanation of these categories, please click here.
		


		
Clinical Activity-Direct Patient Care
		


		


		


		
 
		


		


	
	

		
   Clinical Activity-Education of House Staff
		


		


		


		


		
 
		


		


	
	

		


		


		


		


		


		
       Clinical Activity-Administration
		


		


		


		
 
		


		


	
	

		


		


		


		


		


		
        Other Non-Sponsored Activity
		


		


		


		
 
		


		


	
	

		


		


		


		


		


		


		


		
  Grand Total:
		


		
 
		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
I certify that this report reasonably reflects the activitites for which I, or an employee for whom I have a suitable 
		


		


		


		


		


		


		


		


		


		


		


	
	

		
means of verifying that the work was performed, am/is compensated from the University of Pennsylvania for
		


		


		


		


		


		


		


		


		


		


		


	
	

		
the period covered by this report.
		


		


		


		


		


		


		
CERTIFY
		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		
Name
		


		
Date
		
Title
		


	
	

		
UPHS CLINICAL FACULTY ONLY: 
		


		


		


		


		


		


		


		


		


		


		


	
	

		
Average Weekly Hours - All Activities (Including Sponsored Projects) __________________