Fillable REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY: MILITARY (ENLISTED/ (Uniformed Services University Maryland)

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REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY: MILITARY (ENLISTED/ (Uniformed Services University Maryland)

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MEMORANDUM FOR USUHS ETHICS OFFICIAL/OFFICE OF GENERAL COUNSEL
REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY: MILITARY (ENLISTED/
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 relate 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
SPECIAL INSTRUCTIONS:
All attachments must be dated and signed.
Self-Employment: Indicate self-employment, the type of service (as medical, legal, etc.), whether alone or with
partners, giving their names, and, if providing professional services to a large number of clients or patients,
estimate the total number rather than listing them separately.
Federal Grants or Contracts: Full details must be provided on any aspect of professional and consultative
services that involve, directly or indirectly, the preparation of grant applications, contract proposals, program
reports, and other material designated to become the subject of dealings with the Federal Government.
SIGNATURE OF REQUESTER:
This request is made with full knowledge of applicable USUHS policies regarding outside activities. By
signing this request, I confirm that all the information I have provided is true and accurate to the best of my
knowledge.
Name, Signature and Date of Requestor
RECOMMENDATIONS:
Department Chair/Head (Enlisted) or Office of Student Affairs (Medical Students)
Approve Disapprove
Name, Signature and Date of Dept Chair/Head or OSA
Brigade Senior Enlisted Leader (Enlisted) or Brigade Commandant (Medical Students)
Approve Disapprove
Name, Signature and Date of SEL or Commandant
APPROVAL (PRIOR LEGAL REVIEW REQURIED)
Brigade Commander
Approve Disapprove
Name, Signature and Date of Brigade Commander
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REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY: MILITARY (ENLISTED (Uniformed Services University Maryland)

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Completed 28 August 2020

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