MEMORANDUM FOR USUHS ETHICS OFFICIAL/OFFICE OF GENERAL COUNSEL
REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY: CIVILIANS AND MILITARY
OFFICERS (EXCEPT MEDICAL STUDENTS)
Grade/Rank and Name:
Phone:
Department and Position:
Name and address of business or organization for which the outside activity will be performed:
Nature of the outside activity: (Indicate the type of activity, e.g., teaching or consulting, and give a full
description of the specific duties to be performed.)
Dates and location of outside activity:
From:
To:
Location:
Estimated hours per week (if applicable, include scheduled days of the week) and per month devoted to the
outside activity:
Will the outside activity be performed entirely outside of usual working hours? Yes No If “No”,
indicate estimated time absent from work:
Do your official duties r
elate in any way to the outside activity? Yes No If “Yes”, please describe in
detail:
If providing consulting or professional services, will these services lead to seeking a grant or contract from the
Federal Government? Yes No If “Yes”, please describe in detail:
Indicate any compensation you will receive for the outside activity (check all that apply):
Fee Honorarium Per Diem Royalty Expenses No compensation OR Other
If “Other”, please describe, in detail:
Will compensation be derived from a government grant or contract? Yes No If “Yes”, please describe
in detail:
Indicate if there are attachments included in support of the above information. Attachment: Yes No
OGC Form 2 Rev.
10/16/17
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