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Get File Group Id 4202574 (California Maritime Academy)

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Outside Employment Disclosure Form
For Senior Management Employees
Requirements: This form must be completed by all Senior Management employees (includes the Chancellor, Executive Vice Chancellors,
Vice Chancellors, Presidents, and Vice Presidents) pursuant to Section 42740 of Title 5, California Code of Regulations and the 2016 Budget Act
under the following conditions: upon hire, annually by July 15, within 30 days of accepting outside employment, and within 10 days of request
by an appropriate administrator.
1. Employee Information: Campus: ______________________________________________
Name: ______________________________________________________ Title: __________________________________________________________
2. Type of Disclosure (Check at least one box):
Annual: The period covered is January 1, 20____, through December 31, 20____.
-OR- The period covered is __
___/______/20____ (Time of hire or appointment) through December 31, 20_____.
Time of Hire or Appointment
Accepted outside employment: Outside employment accepted ______/________/20____
Administrator request: The period covered is ______/________/20_____ through ______/________/20_____
-OR - Current outside employment beginning
______/________/20____
3. Outside Employment Involvement (Select “Yes” or “No” for each):
Types of services engaged in during disclosure period:
Please select one:
Paid service* on a federal, state, or local government agency committee, panel, or
commission
Yes
No
Paid service* as an officer or member on a non-profit or for-profit board
Yes
No
Paid service* to organization(s) that further the interests of higher education
Yes
No
Pay* for presentation(s) at scholarly colloquia and conferences, speaker at an event,
and/or guest lecturer
Yes
No
Paid* consulting/professional advising activities
Yes
No
Paid service* as an expert witness
Yes
No
Paid service* on committees/advisory groups to other universities outside the CSU
Yes
No
Paid* for developing scholarly communications or conducting editorial work in books,
journal articles, movies, television productions or similar works
Yes
No
Paid* review of journal/book manuscripts, grant or contract proposals
Yes
No
Other (please specify any other service for which compensation was received): _________________________
____________________________________________________________________________________________________________________
If you answered YES to any of these questions, you have outside employment to report.
*Does not include reasonable incidentals (e.g., travel, meals).
4. Outside Employment Status (Select one):
I have outside employment to report.
I have no outside employment to report (skip to Section 6 for signature and
submit).
5. Detailed Reporting (attach additional pages as necessary):
Outside Employment/Activity 1:
1. Name of outside employer or business:____________________________________________________________________
2. Duration of employment: ____________________________________________________________________________________
3. Describe the nature of the outside employment: _________________________________________________________
_________________________________________________________________________________________________________________
4.
Number of hours for reporting period: ______________________
5. T
otal compensation received including equity or deferred compensation: ____________________________
:____/____/20__
California State University Maritime Academy
✔
6. Does th
e outside employer have any business dealings with CSU? If “yes”, please explain.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7. Are you involved in making any decisions affecting CSU’s dealings with the outside employer
(either directly or indirectly)? Describe: __________________________________________________________________
8. Additional comments (e.g., if compensation was donated, disclose here): _____________________________
_________________________________________________________________________________________________________________
Outside Employment/Activity 2:
1. Name of outside employer or business:____________________________________________________________________
2. Duration of employment: ____________________________________________________________________________________
3. Describe the nature of the outside employment: _________________________________________________________
_________________________________________________________________________________________________________________
4.
Number of hours for reporting period: ______________________
5
. Total compensation received including equity or deferred compensation: ____________________________
6. Does the outside employer have any business dealings with CSU? If “yes”, please explain.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7. Are you involved in making any decisions affecting CSU’s dealings with the outside employer
(either directly or indirectly)? Describe: __________________________________________________________________
8. Additional comments (e.g., if compensation was donated, disclose here): _____________________________
_________________________________________________________________________________________________________________
6. Certification and Review
To be completed by the Employee:
I hereby affirm that the information on this form is accurate to the best of my knowledge, that I have read and
understand my obligations under the CSU’s policy on Outside Employment Disclosure, and that I will comply with
the conditions and restrictions imposed by the CSU to manage, reduce, or eliminate conflicts of
commitment/interest. I certify that my time commitment to the outside employer(s), if applicable, does not create
a conflict of commitment/interest that would interfere with CSU work assignments and satisfactory performance. I
also commit to providing an updated form to my immediate supervisor whenever a significant change occurs in the
information I have provided.
__________________________________________________________ ___________________________
Signature Date
To be completed by the Employee’s Immediate Supervisor/Appropriate Administrator:
I have reviewed this disclosure form and assessed whether the outside employment described above will create a
conflict of commitment or interest between the employee and the CSU. I find that:
the information submitted does not present a conflict of commitment or conflict of interest.
the information submitted may present a conflict of commitment or a conflict of interest.
Comments/recommendations (attach additional pages if necessary):
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
If applicable, submit Form and attachments to the independent review committee for
additional review and approval. Submit completed Form to HR.
Administrator’s Name (Print): __________________________________ Title, Dept: __________________________________________
__________________________________________________________ ___________________________
Signature Date
------------------------------------------------------------------------
------------------------------------------------------------------------------------
IF APPLIC
ABLE - INDEPENDENT REVIEW COMMITTEE (FINAL LEVEL OF REVIEW)
Committee members: _________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________
Select o
ne:
The outside employment does not present a conflict of commitment or conflict of interest.
The outside employment presents a conflict of commitment or conflict of interest.
Determi
nation/Recommendation (Attach additional pages if necessary):
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Completed 18 July 2020

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