Fillable AppendixA Fillable Form2.20.18 (West Georgia College)

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AppendixA Fillable Form2.20.18 (West Georgia College)

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APPENDIX A – UWG Procedure 6.4.2
DISCLOSURE/REQUEST FOR APPROVAL TO ENGAGE IN EXTERNAL ACTIVITY
Instructions. Employees are encouraged to participate in professional activities (e.g. consulting, teaching,
speaking, etc.) that do not interfere with the regular and punctual discharge of official duties, keeping primary
professional loyalty, time, and energy for the University. The specific responsibilities and professional activities
that constitute an appropriate commitment will differ across Colleges/Schools and departments, but they
should be based on a general understanding between the employee and supervisor.
Pursuant to University and Board of Regents policies, a full time University employee must submit this
completed form to his/her supervisor before engaging in external activities.
Form Guidelines.
1. All employees must complete this form:
• at the time of hiring
• upon transfer to a new positon at UWG
• each year at the time of the employee’s performance evaluation
• when any information contained in a previous form needs to be changed or modified, when the
employee engages in a separate activity from the one previously reported
2. A form must be completed for each separate activity.
3. Not Required. A form is not required to be filed for activities undertaken by a faculty member employed
on an academic year contract for activities which begin after the end of spring semester and are
completed before the beginning of the succeeding fall semester, unless that faculty member is employed
to teach one or more courses at the University during that summer semester. Similarly, all employees
are not required to file this form for “Single-Occasion Activities” (activities involving only a few hours,
generally less than one work day, and not recurring on a regular basis or on an established schedule).
4. When an employee undertakes appropriate outside activity, the following conditions are expected to be
observed as part of the employee’s University obligations:
a. Follow established policies and process prior to engaging in any outside activity.
b. Engage only in outside activities that are not in conflict with the employee’s position, that reflect
positively on the department or academic unit and the University, and that do not compete directly
with previously with University needs.
c. Do not use your University position to actively promote outside activities.
d. Do not use University resources (space, equipment, personnel, or other University property) for
outside activities, except where explicit permission has been obtained and appropriate arrangements
for reimbursement have been established.
e. Be prepared to account for the actual amount of time devoted to outside activities and their
appropriateness.
[FORM to be COMPLETED – NEXT PAGE]
FORM TO REPORT OUTSIDE EMPLOYMENT/OTHER COMMITMENTS OR INTERESTS
UWG Procedure 6.4.2 Employee Conflicts of Commitment and Interest
CHECK ONE:
New Hire/Transfer to New Position/New Activity
Changes/Modifications to Existing Form
Additional Form Completed for Separate Activity
Please identify how many separate activities are involved as of the date of signature: _______
1. Type of Activity (Check category below, and explain further in the space provided; be specific and include
the name and address of the related organization):
Occupational. BOR Policy 8.2.15.1 “Outside Activities –Occupational”
Does one of the following apply? If yes, check below.
It is a means of personal professional development?
It serves the community, state, or nation.
Consulting. BOR Policy 8.2.15.2 “Outside Activities – Consulting”
Political. BOR Policy 8.2.15.3 “Outside Activities – Political”
Other (explain below) See, UWG Procedure 6.4.2.
2. Describe the activity, and provide the dates or date range and the amount of time required.
Description:
Date(s):
Time required:
3. Check if this a continuing activity from the previous academic year.
EMPLOYEE IDENTIFICATION. (
Please include all information requested.)
Employee
Name(Printed):
Employee Title:
Department/School:
Supervisor Name:
4. Conflict with Duties/Time Away from Work [STAFF complete]
(Please summarize all activities that may be required during normally scheduled work hours):
Conflict with Duties/Time Away from Work [FACULTY complete]
No classes would require substitute instruction.
Will involve the use of institutional resources (please clarify below).
Will involve cancellation of office hours (please clarify below)
Will involve reduced commitment in service to institution (please clarify below).
Will involve reduced commitment to personal professional development (please clarify below).
Substitute instruction would be required in the following classes (List course number, hour and
location, along with substitute instructor's last name).
Please clarify any responses above here:
[EMPLOYEE SIGNATURE REQUIRED]
By my signature below, I certify that I have read and understand all applicable laws and policies/procedures,
and that all the information given herein is true and correct. I hereby certify that my outside activity
described above does not incur “Conflict of Interest” nor “Conflict of Commitment”. I further understand
that any changes to the information I have given requires that I complete and submit another Disclosure/
Request for Approval to Engage in External Activity:
Employee Signature: ____________________________________ Date: ___________________________
[TO BE COMPLETED BY SUPERVISOR]
The above activity requires the use of institutional resources, and an agreement related to reimbursement is
attached. YES ______ NO ______
The above activity has been reviewed by the person(s) signing below.
Supervisor/Department Head: _________________________________ ___________________
Date
Dean/Director (as applicable): _________________________________ ___________________
Date
Provost/VP (as applicable): _________________________________ ___________________
Date
President (as applicable): _________________________________ ___________________
Date
Comments: ____________________________________________________________________________
______________________________________________________________________________________
A copy of this form should be returned to the employee, a copy should be retained by the unit in accordance
with its procedures, and the original should be forwarded to the Chief Human Resources Officer.
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AppendixA Fillable Form2.20.18 (West Georgia College)

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Completed 20 July 2020

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