ࡱ> @B?a 4/bjbj *lM\M\'R R 8DZL3p[9L(2222222$4r7T2 [[ 23$$$ v2$ 2$$//2P%h2*A![1230L3k17!Z7 /27/2[|$d;22)#~L3 7R > : Top of Form UNIVERSITY OF SOUTH FLORIDA REPORT OF OUTSIDE ACTIVITYEmployee's Name Employee's TitleEmployee's Department CMMB FTE  HTMLCONTROL Forms.HTML:Text.1 \s Employee Type:  HTMLCONTROL Forms.HTML:Checkbox.1 \s Faculty (12 month)  HTMLCONTROL Forms.HTML:Checkbox.1 \s Faculty (9 month)  HTMLCONTROL Forms.HTML:Checkbox.1 \s A&P  HTMLCONTROL Forms.HTML:Checkbox.1 \s  USPS  HTMLCONTROL Forms.HTML:Checkbox.1 \s  Graduate Assistant Name of Employer or Recipient of Services: Location of Proposed Employment or Activity:Funding Source, if compensated: Anticipated Dates of Activity from HTMLCONTROL Forms.HTML:Text.1 \s  to  HTMLCONTROL Forms.HTML:Text.1 \s Number of Days/wk  HTMLCONTROL Forms.HTML:Text.1 \s  Avg Number of Hrs/Wk  HTMLCONTROL Forms.HTML:Text.1 \s Nature and Extent of Activity: NO OUTSIDE ACTIVITY During the course of this activity, do you intend to use the facilities, equipment, or services of the University?  HTMLCONTROL Forms.HTML:Checkbox.1 \s yes  HTMLCONTROL Forms.HTML:Checkbox.1 \s no If yes, please specify: Must you waive patent rights as a condition of this outside activity?  HTMLCONTROL Forms.HTML:Checkbox.1 \s yes  HTMLCONTROL Forms.HTML:Checkbox.1 \s no If yes, prior approval by the tv Vice President for Research is required.Signature of Vice President for Research  HTMLCONTROL Forms.HTML:Checkbox.1 \s  Approved  HTMLCONTROL Forms.HTML:Checkbox.1 \s DisapprovedDateDoes this activity include employment with another state agency?  HTMLCONTROL Forms.HTML:Checkbox.1 \s yes  HTMLCONTROL Forms.HTML:Checkbox.1 \s no If yes, dual compensation approval must be obtained prior to beginning employment.Have you previously filed report(s) of outside activity for the same academic year:  HTMLCONTROL Forms.HTML:Checkbox.1 \s yes  HTMLCONTROL Forms.HTML:Checkbox.1 \s no (Note: A new request must be filed each July 1 if period of activity is in excess of one fiscal year.) If yes, what is the total number of hours of outside activities?  HTMLCONTROL Forms.HTML:Text.1 \s I certify that the outside activity reported herein does not constitute a conflict of interest and will not interfere with my regular employment at the tv.Employee's Signature Date Received by Chair/Supervisor: ReviewerReviewer's SignatureReport AcceptedReport for Accepted/ Conference RequestedDateChair/Supervisor Dean/Director Provost/Vice President or DesigneeDate of Conference, if necessary Result of Conference:  HTMLCONTROL Forms.HTML:Checkbox.1 \s Approved  HTMLCONTROL Forms.HTML:Checkbox.1 \s DisapprovedDistribution: Original to Provost/Vice President; copies to Human Resources, College/Division, and Employee tv Report of Outside Activity OUTSIDE ACTIVITY means "any private practice, private consulting, additional teaching or research or other activity, compensated or uncompensated, which is not part of the employee's assigned duties for which the University has provided no compensation." The Florida Board of Education (FBOE) and the University do not intend to discourage an employee from engaging in outside activity in order to increase professional reputation, service to the community, or income. However, notification and an opportunity to discuss are necessary due to the special obligations and responsibilities of public employees bound by the State of Florida Code of Ethics and dual compensation regulations, in addition to the responsibility for full and competent performance of all duties pertinent to University employment. YOU MUST SUBMIT THE ATTACHED REPORT OF OUTSIDE ACTIVITY FORM IF, DURING A PERIOD IN WHICH YOU HAVE AN APPOINTMENT WITH THE STATE UNIVERSITY SYSTEM: You propose to engage in any compensated or professional outside activity within the above definition or outside activity, AND/OR You propose to engage in any outside activity, compensated or uncompensated, which you should reasonably conclude May create or reasonably appear to create a conflict of interest, OR May otherwise interfere or reasonably appear to interfere with the full performance of your professional responsibilities or other institutional obligations. IN ADDITION, YOU MUST: Submit the report to your supervisor prior to engaging in the subject activity; Refrain from using facilities, equipment, supplies, services or staff of the University in connection with such outside activities without prior approval of the Vice president, which may be conditional upon reimbursement; Take reasonable precautions to ensure that the outside employer or recipient of your services understands that you are engaging in such outside activity as a private citizen and not as an employee, agent, or spokesperson of the University. COMPLETING AND PROCESSING THE REPORT OF OUTSIDE ACTIVITY FORM Fill in all blanks. If not applicable to your report, mark N/A. Make sure that the writing or typing is legible. Your Chair/'Supervisor will review and forward the form. At any level or review a conference may be requested in the event that it appears that this activity may interfere with your obligations and responsibilities or create a conflict of interest. If the matter is not previously resolved, the Vice President shall determine whether the outside activity creates a conflict of interest or otherwise interferes with your professional or institutional responsibilities. You shall be notified of the University's determination no later than three weeks from the date the matter was referred to the Vice President. If you desire to challenge the University's determination and are covered by the collective bargaining agreement, you may request an expedited arbitration hearing under Article 20, Grievance Procedure. Out-of-unit faculty and A&P employees may seek remedy through the tv Grievance Procedure. You may engage in such outside activity pending the decision of the arbitrator or hearing officer. If the arbitrator or hearing officer determines that there is a conflict of interest or other interference with your professional or institutional responsibilities, you shall cease such activity immediately and turn over to the University any compensation earned. _____________________________________________________________________________________________ UNIVERSITY OF SOUTH FLORIDA UNIVERSITY EQUIPMENT, FACILITIES, AND SERVICES To Be Used in Conjunction with Outside Activity Form An employee who has been approved to engage in an outside activity cannot normally expect to use University equipment, facilities, and services. The use of any of these resources will be allowed only on a non-interference basis to the extent that (1) no more than normal depreciation of equipment is experienced and that (2) the use of facilities and services will not result in added expenses accruing to the University. In those instances where added expenses are involved, there will be an appropriate charge for services and facilities. The employee, upon signing this statement, certifies that the use of these University resources is specifically for the purpose of performing employment (consulting) duties for the employer listed on the reverse of this page and does not constitute University competition with private enterprise. EQUIPMENT Identify equipment and manner in which it will be used: __________________________________________________________________________________________________ Department and college or other area(s) in which equipment is located: __________________________________________________________________________________________________ Approval of use of equipment on a non-interference basis: __________________________________________________________________________ ____________________ Signature of Department Chairman and/or Dean or other Supervisor Date FACILITIES Identify facilities and manner in which they will be used:______________________________________________________________________________________________ Department and college or other area(s) in which facilities are located: __________________________________________________________________________________________________ Approval of use of facilities on a non-interference basis: ________________________________________________________________________ ____________________ Signature of Department Chairman and/or Dean or other Supervisor Date SERVICES and COMPUTER Identify services and manner in which they will be used (if computer services, include statement describing class and type of service and description of use ): ______________________________________________________________________ Department and college or other area(s) which will provide services: ___________________________________________ Approval of provision of services at the following (if any) charges: $____________________________________________ _________________________________________________________________________ ____________________ Signature of Department Chairman and/or Dean or other Supervisor Date I assure the University that if in the course of this work, the use of the above University resources changes significantly, a new application will be submitted immediately. ________________________________________________________________________ ________________ Employees signature Date Distribution: Original Vice President for Academic Affairs; copies to: Human Resources, College/Division Central File, Applicant Bottom of Form     Rev.3/05  BDSUe}  ( ) * + ? @ f ۶ۏqdjh[heCJU!j[ heCJOJQJUVjh8bheCJU!j[ heCJOJQJUVheh8bCJjNh[heCJU!j[ heCJOJQJUVjh8bCJU *heh8bCJ h8bCJ heCJ *hehj#CJhj#5CJ\ hj#CJ" (CDTUf$Ifckd$$Ifl4$h%064 laf4 $$Ifa$fg}z $Ifgde$Ifvkd$$Ifl40`$064 laf4 $Ifvkd$$Ifl40$26 064 laf4f g h i o p   G i ѭyoioioi_iN!j[ heCJOJQJUVjhj#CJU hj#CJ *hehj#CJj h8bheCJU!j[ heCJOJQJUV hm$CJjhm$CJU hCJ hpyCJj2 h8bheCJU!j[ heCJOJQJUV h8bCJjh8bCJUjih8bheCJU!j[ heCJOJQJUV    G g h $Ifckd $$Ifl4$h%064 laf4h i R vpp$Ifkdm $$Ifl4F\ $ j6 06    4 laf4     + , N O P Q s $ % & ' - . 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