FOR USE BY VICE CHANCELLOR
FILE NO. ____________________
FORM B approval necessary
[ ] YES [ ] NO
PM-11 FORM A (For FY 20___ - 20____)
Disclosure of Outside Employment
Louisiana State University & Agricultural & Mechanical College AND Louisiana State University Agricultural Center
Baton Rouge, Louisiana Baton Rouge, Louisiana
Louisiana State University Presidential Memorandum Number 11 requires that all full-time employees of the LSU System comply with its
provisions and disclose all outside employment as defined within it. Completion of Form A is required for each outside employment event.
Blanket approvals will not be granted. If the approval of the Chancellor or President is required, Form B must also be attached. Employees are
required to become familiar with PM-11 before completing this form.
EMPLOYEE DISCLOSURE
Employee Name: Name of employer or business:
Department: Time commitment required:
Describe proposed activity below:
1. My outside employment would be with an entity
currently doing or actively seeking to do
business with my unit at the University. [ ] Yes [ ] No
4. I am collaborating with or on special assignment to
a unit within the University with which the company
is doing or is seeking to do business. [ ] Yes [ ] No
2. My outside employment would involve teaching 5. My outside employment would yield results
which results in university level credit, will which advance a theory or practice in my
be conducted on University time or field.
will utilize University property or services. [ ] Yes [ ] No [ ] Yes [ ] No
3. My outside employment would involve my providing 6. My outside employment would result in my receiving
professional, personal, consulting and social compensation to assist in the passage or defeat of
services to a department, commission, council, state legislation during the fiscal year in which
board, office, bureau, committee, institution, the legislation was pending in the legislature.
agency, government, corporation, or any other
establishment of the Executive Branch of the
State of Louisiana. [ ] Yes [ ] No [ ] Yes [ ] No
I will explain to the proposed outside employer that: (1) I do not represent said outside employer as an employee of the University in any
manner, (2) any views I express on behalf of an outside employer do not necessarily reflect the view of the University, and (3) in no way may
the name of the University nor my official University capacity be used in support of any position I may take on behalf of said outside employer.
Furthermore, I certify that University personnel, laboratories and equipment will not be used in connection with outside employment other than
as provided in PM-11.
My signature attests to my understanding of and compliance with PM-11.
Name: Title:
Signature: Department:
Date:
NOTE: If #3 and/or #10 is YES, needs President’s approval and Form B. If any answers #1-10 are YES, needs Chancellor’s approval
and Form B. If all answers #1-10 are NO, Vice Chancellor’s approval is all that is needed and do not attach Form B.
PM11FORM.993
