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Pm-11-LSUBRCampus PM-11 FORM A

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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
ADMINISTRATIVE REVIEW
Circle the number corresponding to any employee responses with which you disagree.
Department Chair/Head/Institute Director [1] [2] [3] [4] [5] [6]
Dean/Executive Director [1] [2] [3] [4] [5] [6]
Vice Chancellor (ORED/Ag Center) [1] [2] [3] [4] [5] [6]
Indicate your agreement or disagreement with the following statements.
7. The proposed duties ordinarily would be performed as part of Department Chair/Head/Institute Director [ ] Yes [ ] No
the public service portion of the employee’s duties and Dean/Executive Director [ ] Yes [ ] No
responsibilities. Vice Chancellor (ORED/Ag Center) [ ] Yes [ ] No
8. The proposed activity more appropriately would be accomplished Department Chair/Head/Institute Director [ ] Yes [ ] No
by a contract through the University. Dean/Executive Director [ ] Yes [ ] No
Vice Chancellor (ORED/Ag Center) [ ] Yes [ ] No
9. The legal entity for which the outside employment is proposed Department Chair/Head/Institute Director [ ] Yes [ ] No
has substantial economic interest which may be materially Dean/Executive Director [ ] Yes [ ] No
affected by the way in which the employee performs his or her Vice Chancellor (ORED/Ag Center) [ ] Yes [ ] No
duties and responsibilities as a University employee.
10. The outside employment involves public policy. Department Chair/Head/Institute Director [ ] Yes [ ] No
Dean/Executive Director [ ] Yes [ ] No
Vice Chancellor (ORED/Ag Center) [ ] Yes [ ] No
ADMINISTRATIVE APPROVALS
If the answer is YES to either question [3] or [10], the President’s approval is required. If the answer is YES to any other question, the
Chancellor’s approval is required. If all responses are NO, then outside employment may be approved by the Vice Chancellor for Research
and Economic Development (ORED)/Vice Chancellor & Director for Research (Ag Center).
[ ] RECOMMENDED
[ ] NOT RECOMMENDED
Signature:
____________________________________________________________ ____________________
Department Chair/Head/Institute Director Date
[ ] RECOMMENDED
[ ] NOT RECOMMENDED
Signature:
____________________________________________________________ ____________________
Dean/Executive Director Date
ACTION BY VICE CHANCELLOR FOR RESEARCH AND ECONOMIC DEVELOPMENT
Louisiana State University & Agricultural & Mechanical College
[ ] APPROVED
[ ] DISAPPROVED
[ ] Forwarded thru Chancellor for action by President
[ ] Returned to employee for compliance with PM-11
requirements requiring approval of Chancellor.
Signature:
____________________________________________ ____________________
Vice Chancellor for Research & Economic Development Date
ACTION BY VICE CHANCELLOR & DIRECTOR FOR RESEARCH OR EXTENSION
Louisiana State University & Agricultural & Mechanical College
[ ] APPROVED
[ ] DISAPPROVED
[ ] Forwarded thru Chancellor for action by President
[ ] Returned to employee for compliance with PM-11
requirements requiring approval of Chancellor.
Signature:
____________________________________________
Vice Chancellor & Director for Research or Extension
____________________
Date
All reviewing administrators hereby certify that they have read and are familiar with the Louisiana Code of Governmental Ethics and that
approval of this outside employment does not knowingly violate the Code of Ethics, PM-11 or any other rule or regulation of the University.
PM11FORM.994
FOR USE BY VICE CHANCELLOR
FILE NO. ____________________
FORM B approval necessary
[ ] YES [ ] NO
PM-11 FORM B
Disclosure of Outside Employment
Louisiana State University & Agricultural & Mechanical College AND Louisiana State University Agricultural Center
Baton Rouge, Louisiana Baton Rouge, Louisiana
If outside employment requires approval by the Chancellor or the President, the employee must follow the certification and contractual provisions
of
PM-11 under the Approval Level section for outside employment. All required documents shall be attached to and made a part of this
Disclosure Form before submission through administrative channels for review by the Chancellor. The following approvals must be obtained
before engaging in the proposed outside employment.
EMPLOYEE DISCLOSURE
Employee’s Name: ________________________________________________________________________________________________
Proposed outside employer or business: _______________________________________________________________________________
Proposed compensation to be received: ______________________________________ Date: ________________________________
APPROVAL/CERTIFICATION BY CHANCELLOR
The outside employment activities are not within the course and scope of the employee’s duties to the University for which the employee is
being compensated by the University.
The outside employment activities do not conflict, delay or in any manner interfere with instructional, scholarly and/or services which the
employee is obligated to perform for the University.
The consulting activities to be performed are within the academic or professional discipline of the employee or are related to the area of
expertise in which the employee is employed by the University.
Signature:
______________________________________________________________________ ____________________________________
Chancellor Date
Louisiana State University & Agricultural & Mechanical College
AND/OR
Signature:
______________________________________________________________________ _____________________________________
Chancellor Date
Louisiana State University Agricultural Center
OUTSIDE EMPLOYMENT INVOLVING PUBLIC POLICY OR A STATE AGENCY
[ ] APPROVED
[ ] NOT APPROVED
Signature:
___________________________________________________ _____________________________________
President Date
PM11FORM.994
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Completed 21 February 2020

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