Fillable Hhs-521 FORM HHS-521

Fill Online, Printable, Fillable, Blank Hhs-521 FORM HHS-521 Form

Use Fill to complete blank online HEALTH AND HUMAN SERVICES (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Hhs-521 FORM HHS-521

On average this form takes 43 minutes to complete

The Hhs-521 FORM HHS-521 form is 16 pages long and contains:

  • 4 signatures
  • 52 check-boxes
  • 131 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Health and Human Services

BROWSE HEALTH AND HUMAN SERVICES (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ANNUAL REPORT OF OUTSIDE ACTIVITY
Executive Branch Financial Disclosure Regulation
HHS Supplemental Financial Disclosure Regulation
(5 CFR Part 2634, 5 CFR Part 5502)
CALENDAR YEAR REPORTING PERIOD
2 0
DUE ANNUALLY ON FEBRUARY 28
EXTENSION DATE
DATE REPORT FILED
I. EMPLOYEE INFORMATION
1. EMPLOYEE'S NAME (Last, First, MI)
2. AGENCY (Operating/Staff Division) (Subcomponent)
3. TITLE OF POSITION
4. GRADE/STEP
5. FEDERAL SALARY
6. APPOINTMENT TYPE
PAS/PA
Non-Career SES Career SES
Schedule C
Commissioned Corps
GS
Title 42
Other
7. FINANCIAL DISCLOSURE FILING STATUS
Public (OGE 278)
Confidential (OGE 450)
None
8. OFFICE ADDRESS
STREET
CITY
STATE
ZIP
9. OFFICE CONTACT INFORMATION
TELEPHONE FAX
CELL EMAIL
10. NAME OF IMMEDIATE SUPERVISOR 11. TITLE OF SUPERVISOR
12. SUPERVISOR CONTACT INFORMATION
TELEPHONE
FAX
CELL EMAIL
AGENCY USE ONLY
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 1 OF 10
II. OUTSIDE ACTIVITY INFORMATION
1. Outside Activity List
List below all outside activities for which prior approval is required that were approved or undertaken within the last calendar year. Provide the date of
approval, identify the person for whom or the organization with which the activity was to be conducted, and check the box marked ( ) if the activity was
actually performed.
OUTSIDE ACTIVITY PERSON OR ORGANIZATION
APPROVAL DATE
(mm/dd/yy)
( )
A.
B.
C.
D.
E.
2. Duration
In the line that corresponds to the same letter that identifies the activity above, provide, for each outside activity actually performed, the beginning date
of the relationship with the outside entity, the date(s) personal services were provided, and the total number of hours spent and leave used on the
activity in the last calendar year. Specify the ending date; or for an ongoing activity, indicate how long the activity may continue and the date prior
approval expires. Check whether renewal is anticipated.
BEGINNING DATE
(mm/dd/yy)
SERVICE DATE(S)
(mm/dd/yy)
HOURS
SPENT
LEAVE
USED
ENDING DATE
(mm/dd/yy)
RENEWAL
ANTICIPATED?
A.
NoYes
B.
NoYes
C.
Yes No
D.
NoYes
E.
NoYes
3. Income and/or Reimbursements Paid
In the line that corresponds to the same letter that identifies the activity above, provide, for each outside activity actually performed, the type and
amount of any income and/or reimbursements actually received during the last calendar year and the date paid. If none, check the box.
PAYMENT
RECEIVED
INCOME AND/OR
REIMBURSEMENT TYPE
AMOUNT
DATE(S) PAID
(mm/dd/yy)
A.
None
$
B.
None
$
C.
None
$
D.
None
$
E.
None
$
4. Income and/or Reimbursements Due
In the line that corresponds to the same letter that identifies the activity above, provide, for each outside activity actually performed, the type and
amount of any income and/or reimbursements earned during or attributable to the last calendar year that were not in fact received during the reporting
period and remain due, and indicate the expected date of payment. If none, check the box.
PAYMENT
DUE
INCOME AND/OR
REIMBURSEMENT TYPE
AMOUNT
DATE(S) PAYMENT DUE
(mm/dd/yy)
A.
None
$
B.
None
$
C.
None
$
D.
None
$
E.
None
$
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 2 OF 10
II. OUTSIDE ACTIVITY INFORMATION (continued)
5. Employee Questions
a. Have you been appointed or reassigned to a different Federal position within the Department since any outside activity reported on this form was
approved or undertaken?
Yes
(If this box is checked, answer when and explain. Copies of the approved HHS Form 520 for each activity should be provided to any new
supervisor.)
No
b. Have the duties and responsibilities of your current Federal position changed since any outside activity reported on this form was approved or
undertaken?
Yes
(If this box is checked, answer when and explain.)
No
c. For any outside activity reported on this form, has any change occurred or is any change anticipated with respect to the information previously
furnished on the corresponding HHS Form 520?
Yes
(If this box is checked, explain.)
No
d. For any outside activity reported on this form, has the nature, scope, or subject matter changed?
Yes
(If this box is checked, explain.)
No
e. Did you answer “Yes” to one or more of the Questions 5. a., b., c., or d.? If so, a revised request for approval must be submitted on a new HHS
Form 520.
Yes
(If this box is checked, submit the form to your immediate supervisor.)
No
6. CERTIFICATION
The undersigned employee certifies that the notices in Part VI have been read and understood and that the statements made and information provided on
this form are true, complete, and correct to the best of the individual’s knowledge.
EMPLOYEE SIGNATURE DATE
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 3 OF 10
click to sign
signature
click to edit
III. SUPERVISOR REVIEW
An employee cannot undertake an outside activity that conflicts with the employee's official duties. An activity conflicts with official duties: (a) if it is
prohibited by statute or regulation; or (b) if, under the standards in 5 CFR 2635.402 and 2635.502, it would require the employee’s recusal from matters
so central or critical to the performance of his or her official duties that the employee's ability to perform the duties of his or her position would be
materially impaired. Such a recusal would likely arise where the outside activity involves a person or entity that is regulated by, does business with,
receives grants or other benefits from, or is otherwise substantially impacted by the programs, policies, and operations of the employee’s agency, and the
employee normally would be involved personally and substantially in such matters on a frequent basis or as a principal duty. In addition, an activity
may be improper if the circumstances suggest that the employee received an outside business opportunity based on his or her official position or would
create the appearance of using public office for the private gain of an outside entity. An employee also must endeavor to avoid any actions that create the
appearance of a violation of law or the ethical standards. Special rules apply to activities involving fundraising, expert witness testimony, teaching,
speaking, writing, or editing, and activities with foreign entities. Certain categories of employees, such as those in FDA, NIH, and OGC, are subject to
component specific rules on outside activities. Refer to the Standards of Ethical Conduct, 5 CFR part 2635, subpart H, and the HHS Supplemental
Ethics Regulation, 5 CFR part 5501.
The undersigned supervisor, identified in Part I, Item 10, has evaluated the responses and any supporting documentation of the employee, reviewed
the HHS Form 520s on file, and obtained additional information where appropriate. Based on this information, the supervisor makes the following
determination:
No Action Required
(If this box is checked, the undersigned concludes that the employee is in compliance with applicable laws and regulations (subject to any
comments in the box below) and that no legal or ethical impediment has been identified that would have precluded the approval of any listed
outside activity or that would require the cancellation of any ongoing outside activity. Describe the basis for this conclusion in the "Comments"
box below.)
Corrective Action Required (If this box is checked, describe in the box below.)
SUPERVISOR SIGNATURE DATE
3. Comments
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 4 OF 10
1. Summary of Applicable Law
2. Review
click to sign
signature
click to edit
IV. MANAGEMENT / COMMITTEE / OTHER INTERMEDIATE REVIEW
1. Name of Reviewer 2. Title of Reviewer
3. Reviewer Contact Information
TELEPHONE FAX
CELL EMAIL
4. Organization
5. Committee
If the reviewer acts on behalf of a committee, identify the body and record any dissenting views in the "Comments" below.
6. Review
Review the employee's answers and indicate whether you concur in the supervisor's determination. Explain your reasons in the space below. Sign and
date the form in the space provided.
Concur
Nonconcur
REVIEWER SIGNATURE DATE
7. Comments
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 5 OF 10
click to sign
signature
click to edit
V. AGENCY ETHICS OFFICIAL REVIEW
1. Name of Agency Ethics Official 2. Title of Agency Ethics Official
3. Agency Ethics Official Contact Information
TELEPHONE
FAX
CELL EMAIL
4. Organization
5. Ethics Review
Review the employee's answers and the supervisor's determination. Consider the assessment of any management official, committee, or other intermediate
reviewer. Indicate whether you concur in the supervisor's determination. Explain your reason(s) in the space below and describe any actions deemed
necessary to ensure compliance with applicable ethics laws. Sign and date the form in the space provided.
Concur
Nonconcur
AGENCY ETHICS OFFICIAL SIGNATURE DATE
6. Comments
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 6 OF 10
click to sign
signature
click to edit
VI. NOTICES
APPROVAL OF AN OUTSIDE ACTIVITY DOES NOT RELEASE YOU FROM A CONTINUING LEGAL OBLIGATION TO
DISQUALIFY YOURSELF FROM OFFICIAL ASSIGNMENTS AFFECTING YOUR OUTSIDE EMPLOYER OR THE ENTITY
TO WHICH YOU ARE PROVIDING PERSONAL SERVICES. WHILE PERFORMING AN APPROVE OUTSIDE ACTIVITY,
ANY ACTIONS TAKEN IN CONFLICT WITH APPLICABLE ETHICS LAWS MAY SUBJECT YOU TO CRIMINAL
PROSECUTION OR DISCIPLINARY PROCEEDINGS.
Caution. When you consult, teach, speak, write, serve on a board,
or work for a company, organization, or other entity outside your
government job, your relationship with that outside entity has
certain legal and ethical consequences. The approval of an outside
activity does not mean that you are free of conflicts of interest. You
must still follow all substantive ethics requirements after approval is
granted. Consult the ethics regulations at 5 CFR 2635.802 and
5501.106(d)(5) which are reprinted below.
Conflicts Resolution. An approved HHS Form 520 does not
signify that you need not be concerned about conflicts of interest.
Under the law, conflicts of interest arising out of outside
employment or service in a fiduciary position can be resolved in
advance in only three ways: (1) you can inform your supervisor and
disqualify yourself from participating in a conflicting government
matter (often called a recusal); (2) you can seek, if certain legal
requirements are satisfied, a separate legal document from your
appointing official or designee that specifically permits you to work
on the government matter (known as a waiver), or (3) you can
resign from either your government or outside job. Outside
relationships that fall short of actual employment or a fiduciary role
pose similar appearance concerns that must be addressed under
procedures in 5 CFR 2635.502.
Effect of Prior Approval. The outside activities prior approval
process has very limited purposes. When a reviewer approves an
HHS Form 520 for your outside activity, two fundamental
assessments are being made, which are discussed below. You
reasonably may rely on these specific determinations only if you
provided all relevant information on the form and the
circumstances under review do not thereafter change. You remain
responsible for the legal and ethical consequences of any change
in personal or business affairs or a change in your government
duties.
First, based on the information which you provide, the reviewer
determines whether your proposed activity is plainly prohibited by
applicable statutes or regulations, including the provisions of the
ethical standards governing appearances of impropriety. For
example, if you want to lobby Federal agencies on behalf of a non-
profit organization that employs you, prior approval will be denied
because a criminal statute prohibits such representational
activities.
Second, assuming your proposed activity is not specifically
prohibited, the reviewer determines whether, under the circum-
stances, approval should be denied for other reasons specified
under the law. For example, the reviewer may deny approval if the
facts show that you used your government position to obtain an
outside compensated business opportunity or if the activity would
create the appearance that you are violating the law or the ethical
standards. Another common reason for denying approval is that
the outside activity may prevent you from handling work that is
expected of you. Because the outside activity may cause you to
have to disqualify yourself from a broad range of job assignments,
or even a few crucial projects, that will affect your outside employer
or the entity to which you provide personal services, it may be
impossible for you to discharge fully your government duties.
If, however, your outside activity is approved, the reviewer has
determined that the matters in which you will not be allowed to
participate are not “so central or critical to the performance of [your]
official duties” that your ability to perform the duties of your position
would be materially impaired. In other words, you cannot work on a
government matter affecting your outside employer, but the
reviewer expects that you will be able to stay away from these
assignments and still do your job.
Recusal Obligations. When performing your Federal duties, you
must not participate in any government matter that will affect your
own self-interest in continuing your outside job or activity. For
example, you would have to disqualify yourself from participating in
any official matter that might put your outside employer out of
business or seriously affect its finances, either positively or
negatively, so that the odds of your remaining employed are also
affected. In addition, when you work for an outside employer or
serve in a fiduciary role with an organization, the financial interests
of that company or organization are considered to be your own. As
a result, if the company or organization has a financial interest in
how a government matter will be resolved, you cannot work on that
matter. This means that you cannot work on a government matter
that involves or affects your outside employer as a specific party,
such as a contract, grant, audit, investigation, or litigation. The law
also requires you to stay away from government matters that are
larger in scope, such as deliberations and decisions on developing,
implementing, or enforcing statutes, regulations, policies, studies,
or proposals, that will have an effect on a large class of employers
like the one for which you work on the outside. For example, if you
were permitted to have an outside position as an employee of a
hospital, a drug company, or a nonprofit organization, you could not
participate personally in any significant way in a policy decision that
affects the financial interests of the industry or organizational sector
in which these employers operate. Under certain limited
circumstances, a waiver for such “particular matters of general
applicability” can be considered, if you notify your appointing official
in advance and receive a written determination. Outside relation-
ships that fall short of actual employment or a fiduciary role pose
similar appearance concerns, but the recusal obligation is limited to
specific party matters.
Scope of Recusal. Although many employees understand the
need to disqualify themselves from participating in an official matter
that affects their outside employer, they often believe erroneously
that they can pick and choose among the various aspects of a
particular matter and stay away only from the important decisions.
Such incomplete recusals will not protect you from a criminal
conflict of interest violation. Unless a waiver, approved in advance,
identifies specific permitted activities, you must refrain entirely and
absolutely from participating personally and substantially in a
government matter that affects your own financial interest or that of
an outside employer. When you are involved significantly in
proposing, planning, advising, deciding, or implementing some
official action, and you do so individually or by actively directing
subordinates, your participation is personal and substantial.
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 7 OF 10
VI. NOTICES (continued)
EXCERPTS FROM THE STANDARDS OF ETHICAL CONDUCT FOR EMPLOYEES OF THE EXECUTIVE BRANCH AND
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES SUPPLEMENTAL AGENCY ETHICS REGULATIONS:
TITLE 5 CODE OF FEDERAL REGULATIONS
§ 2635.802 Conflicting outside employment and activities.
An employee shall not engage in outside employment or any other
outside activity that conflicts with his official duties. An activity
conflicts with an employee's official duties:
(a) If it is prohibited by statute or by an agency supplemental
regulation; or
(b) If, under the standards set forth in §§ 2635.402 and 2635.502,
it would require the employee's disqualification from matters so
central or critical to the performance of his official duties that the
employee's ability to perform the duties of his position would be
materially impaired.
Employees are cautioned that even though an outside activity may
not be prohibited under this section, it may violate other principles
or standards set forth in this part or require the employee to
disqualify himself from participation in certain particular matters
under either subpart D or subpart E of this part.
Example 1: An employee of the Environmental Protection Agency
has just been promoted. His principal duty in his new position is to
write regulations relating to the disposal of hazardous waste. The
employee may not continue to serve as president of a nonprofit
environmental organization that routinely submits comments on
such regulations. His service as an officer would require his
disqualification from duties critical to the performance of his official
duties on a basis so frequent as to materially impair his ability to
perform the duties of his position.
Example 2: An employee of the Occupational Safety and Health
Administration who was and is expected again to be instrumental in
formulating new OSHA safety standards applicable to manu-
facturers that use chemical solvents has been offered a consulting
contract to provide advice to an affected company in restructuring
its manufacturing operations to comply with the OSHA standards.
The employee should not enter into the consulting arrangement
even though he is not currently working on OSHA standards
affecting this industry and his consulting contract can be expected
to be completed before he again works on such standards. Even
though the consulting arrangement would not be a conflicting
activity within the meaning of § 2635.802, it would create an
appearance that the employee had used his official position to
obtain the compensated outside business opportunity and it would
create the further appearance of using his public office for the
private gain of the manufacturer.
§ 5501.106(d)(5) Standard for approval.
Approval shall be granted only upon a determination that the
outside employment or other outside activity is not expected to
involve conduct prohibited by statute or Federal regulation,
including 5 CFR part 2635 and this part.
Note: The granting of approval for an outside activity does
not relieve the employee of the obligation to abide by all
applicable laws governing employee conduct nor does
approval constitute a sanction of any violation. Approval
involves an assessment that the general activity as described
on the submission does not appear likely to violate any
criminal statutes or other ethics rules. Employees are
reminded that during the course of an otherwise approvable
activity, situations may arise, or actions may be contemplated,
that, nevertheless, pose ethical concerns.
Example 1: A clerical employee with a degree in library science
volunteers to work on the acquisitions committee at a local public
library. Serving on a panel that renders advice to a non-Federal
entity is subject to prior approval. Because recommending books
for the library collection normally would not pose a conflict with the
typing duties assigned the employee, the request would be
approved.
Example 2: While serving on the library acquisitions committee,
the clerical employee in the preceding example is asked to help the
library business office locate a missing book order. Shipment of the
order is delayed because the publisher has declared bankruptcy
and its assets, including inventory in the warehouse, have been
frozen to satisfy the claims of the Internal Revenue Service and
other creditors. The employee may not contact the Federal
bankruptcy trustee to seek, on behalf of the public library, the
release of the books. Even though the employee's service on the
acquisitions committee had been approved, a criminal statute, 18
U.S.C. 205, would preclude any representation by a Federal
employee of an outside entity before a Federal court or agency with
respect to a matter in which the United States is a party or has a
direct and substantial interest.
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 8 OF 10
PRIVACY ACT STATEMENT
The Ethics in Government Act, 5 U.S.C. App. § 101, et seq., Executive Order 12674, as amended by Executive Order 12731,
Sections 301 and 7301 of Title 5 of the U.S. Code, and Sections 2634.103, 2635.803, 5501.106(d), 5502.102, and 5502.103 of
Title 5 of the Code of Federal Regulations authorize the collection of this information. Disclosure of this information is mandatory for
employees who have received prior authorization from an agency designee to pursue outside employment or activities pursuant to
Sections 2635.803 and 5501.106(d) of Title 5 of the Code of Federal Regulations or who have performed an outside activity for
which prior approval under those sections is required. Failure to provide all or part of the requested information may result in
cancellation of approval for any continuing outside employment or activity. Falsification of information or failure to file or report
information required to be reported may subject the employee to disciplinary action. Knowing and willful falsification of information
required to be reported may subject the employee to criminal prosecution. The primary use of this information is to allow HHS
supervisors, management officials, and agency ethics officials to determine whether the continuation of a previously approved
outside activity would pose a conflict of interest as a result of any modification in an employee’s duties or assignments or change in
the activities or operations of the outside entity. The information may also be used to evaluate the determinations concerning
employee requests for prior approval of outside employment or activities in order to prevent other violations of the statutes,
regulations, and executive orders governing employee conduct. The information is also requested, pursuant to 5 C.F.R. §§ 2638.203
(b)(9),(10), and (11), for the purpose of evaluating ethics program administration, as well as the Department’s supplemental ethics
regulations, to determine their continued adequacy and effectiveness in relation to current agency responsibilities and to ensure that
prompt and effective action is taken to remedy violations or potential violations, or appearances thereof, of conflict of interest and
related ethics provisions. Additionally, this information may be disclosed to: (1) the Office of Personnel Management, Office of
Government Ethics, Merit Systems Protection Board, Office of the Special Counsel, Equal Employment Opportunity Commission,
Federal Labor Relations Authority, Federal Service Impasses Panel, Federal Mediation and Conciliation Service, and an arbitrator,
in carrying out their functions; (2) a Federal, State, or local agency charged with investigating or prosecuting violations of, or
implementing, the law, in the event there is an indication of a violation or potential violation of civil, criminal or regulatory law; (3) a
Federal, State, or local agency maintaining enforcement records or other pertinent records, such as current licenses, if necessary to
obtain a record relevant to an agency decision concerning the hiring or retention of an employee, the issuance of a security
clearance, the letting of a contract, or the issuance of a license, grant or other benefit; (4) the National Archives and Records
Administration or the General Services Administration in records management inspections; (5) the Office of Management and
Budget during legislative coordination on privacy relief legislation; (6) Federal agencies with power to subpoena other Federal
agencies’ records; (7) a court or party in a court or Federal administrative proceeding if the Government is a party or in order to
comply with a judge-issued subpoena; (8) private firms with which the Department may contract for the purpose of collating,
analyzing, aggregating or otherwise refining records; (9) a Member of Congress or a Congressional office, pursuant to an inquiry
made at the request of the individual who is a subject of the record; (10) the Department of Justice in defense of litigation; and (11)
contractors and other non-Government employees working for the Federal Government to accomplish a function related to an Office
of Government Ethics Government-wide system of records. This confidential report will not be disclosed to any requesting person
unless authorized by law. See the OGE/GOVT-2 Government-wide executive branch system of records.
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 9 OF 10
ADDITIONAL SPACE
Identify the part and item number to which the additional information refers.
Department of Health and Human Services
Office of the Secretary
Office of the General Counsel
Ethics Division
Washington, DC 20201
(202) 690-7258
HHS-521 (1/06) (Previous Editions Obsolete)
PAGE 10 OF 10
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Hhs-521 FORM HHS-521

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document