Fillable Section A Preliminary Approval of Dual Appointment Engagement (Darton State College)

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Section A Preliminary Approval of Dual Appointment Engagement (Darton State College)

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Dual Appointment Agreement
Last Revision: 06/21/2016
1
Section A – Preliminary Approval of Dual Appointment Engagement
Employee Name
Employee ID
Institution Name
Request Date
Requested Dates of Service
General Description of Dual Appointment Engagement
Type of Dual Appointment (Refer to Human Resources Administrative Practices Manual (HRAP) Dual
Appointment Section for definitions)
Full-Time Equivalent Dual Appointment
More than Full-Time Equivalent Dual Appointment *
Part Time/Temporary Dual Appointment *
*If the engagement is considered “More than Full-Time Equivalent Dual Appointment” or “Part-
Time/Temporary Dual Appointment”, please verify the employee meets one of the following
exceptions as defined in O.C.G.A. 45-10-20.
Doctoral or Master’s Degree from an accredited college or university
Licensed physician
Dentist
Psychologist
Registered nurse or licensed practical nurse
Certified oral or manual interpreter for deaf person
Chaplain
Firefighter
Teacher/instructor of an evening or night course or program
The signatures below certify that the employee and their supervisor have discussed the potential dual
appointment engagement and that such service will not have a detrimental effect on their Home
Institution work commitment.
Employee Name
Date
Signature
Email
Direct Supervisor Name
Date
Signature
Email
click to sign
signature
click to edit
click to sign
signature
click to edit
Dual Appointment Agreement
Last Revision: 06/21/2016
2
Section B – Dual Appointment Coordinator Information
Requesting Institution
Contact Name
Phone
Title
Email
Home Institution
Contact Name
Phone
Title
Email
Section C – Employee Information
Home Institution Commitment
Employee Name
Employee ID
Institution Name
Employee’s Direct Supervisor
Title
Department
Employee Category/Status (Refer to HRAP: Classification, Compensation and Payroll)
Staff
Faculty
Student
Rehired Retiree
Regular
Temporary
Full-Time
Part Time – Complete Part Time Compliance Statement (Appendix A)
Exempt
Non-exempt*
Do the Requesting Institution obligations result in a change to the employee’s FLSA status?
Yes
No
New FLSA Status:
Exempt
Non-exempt*
* Earned overtime will be paid at the rate assigned to the position that incurs the overtime.
*If Employee’s duties at Home Institution are non-instructional, only required to fill out Institution and
Standard Hours. If Employee’s duties are instructional, all columns are required.
Current Obligations *
Institution
Credit Hours
Contact
Hours
Standard
Hours
Begin Term
Date
End Term
Date
Dual Appointment Agreement
Last Revision: 06/21/2016
3
Requesting Institution Requested Commitment
Institution Name
Request Date
Requested Dates of Service
New Background Check Needed for Position? Yes □ No □
Need for and description of services to be performed
Justification for obtaining services from another USG employee in lieu of obtaining such services from
a person not presently employed by Institution.
Requested Obligations*
Institution
Credit
Hours
Contact
Hours
Standard
Hours
Begin Term
Date
End Term
Date
*If Employee’s duties at Requesting Institution are non-instructional, only required to fill out Institution
and Standard Hours. If Employee’s duties are instructional, all columns are required.
For More than Full-Time Equivalent Dual Appointment of full-time, benefitted Employees (not
Shared), is the compensation pensionable?
Yes* □ No □
*Refer to the Additional Compensation/Overload policies for Faculty and Staff.
Dual Appointment Agreement
Last Revision: 06/21/2016
4
Section D – Payment and Invoicing Details
Compensation Details
Amount
Fund
Dept
Program
Class
Project #
Grant
Institution
Responsible
HI OR RI
Fee for Service
FICA – 6.2%
FICA (Med) –
1.45%
Health & Welfare
Benefits
Retirement
Background
Check
Other
Estimated
Reimbursable
Expense (travel,
parking, etc.)
Total
Home Institution Invoice and Payment Details
The Home Institution will invoice the Requesting Institution:
One Time (End of Service)
Quarterly
Monthly
Other (specify)
The Home Institution will pay the Employee:
Monthly
Biweekly
0.00
Dual Appointment Agreement
Last Revision: 06/21/2016
5
Section E – Signatures
Employee Signature
The signature below certifies that the employee agrees to the dual appointment engagement as defined
in this agreement.
Employee Name
Date
Signature
Email
Requesting Institution Signatures
The signatures below certify that the Requesting Institution agrees to pay the compensation details total
as outlined above to the Home Institution. The signatures also affirm that the Requesting Institution is
responsible for notifying the Home Institution of any changes to the compensation details or requested
obligations.
Dean/Administrative Dept.
Head
Date
Signature
Email
President/Designee
Date
Signature
Email
Home Institution Signatures
The signatures below certify that the requested employee is available to perform the described services
and that the performance of these services will not detract from nor have a detrimental effect on the
performance of the person’s employment at the Home Institution. They also affirm the invoice,
payment and compensation details as outlined.
Dean/Administrative
Dept. Head
Date
Signature
Email
VP Academic Affairs
Date
Signature
Email
President/Designee
Date
Signature
Email
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signature
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signature
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signature
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signature
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signature
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signature
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Dual Appointment Agreement
Last Revision: 06/21/2016
6
Section F – Additional Approval Signatures (as required by Institutions, e.g. CBO, Accounting Office)
Institution
Name
Title
Signature
Date
Email
Institution
Name
Title
Signature
Date
Email
Institution
Name
Title
Signature
Date
Email
Institution
Name
Title
Signature
Date
Email
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signature
click to edit
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signature
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signature
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signature
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Dual Appointment Agreement
Last Revision: 06/21/2016
7
Appendix A – Part Time Compliance Statement
Acknowledgement of the USG Part-time Policy Compliance Statement (Refer to the Academic & Student
Affairs Handbook, Section 4.2, Definition of Part-Time).
Part-time faculty are non-tenured faculty employed at a single USG institution or at more than one USG
institution and are subject to the following conditions:
1. Are employed as-needed, on a per-course, per semester limited term basis at the discretion of
the institution and will receive no compensation unless a part-time assignment is given
2. Are not accruing time toward tenure
3. Are required to sign a letter of agreement for each appointment period and are not issued
contracts
4. Are not the same as adjunct (courtesy) faculty appointments
5. Are not eligible for USG benefits, unless the part-time appointment is regular and .5 FTE or
greater, in which case the benefits offered will be based on FTE in accordance with the
Employees Categories policy in the Human Resources Administrative Practices Manual
6. Are required to work an average of less than 30 hours per week over the academic year. Hours
worked per week are based on Contact hours. See conversion chart (in the Employee
Categories policy in the Human Resources Administrative Practices Manual,
http://www.usg.edu/hr/manual/employee_categories) to determine the number of contact
hours that can be assigned to the part-time faculty to meet the less than 30 hours per week
condition
A faculty member employed at an institution at a .75 FTE or greater, other than in a temporary status
based on the definition in the Employee Categories policy in the Human Resources Administrative
Practices Manual, http://www.usg.edu/hr/manual/employee_categories, must be considered benefits
eligible and treated accordingly.
Compliance Statement:
I certify that I have read the above policy and am in compliance with this policy.
Employee
Date
Signature
Email
click to sign
signature
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Dual Appointment Agreement
Last Revision: 06/21/2016
8
Appendix B – Dual Appointment Delayed Agreement Execution Justification
Provide a written justification for the late notice Agreement Execution
Appendix C – Dual Appointment Agreement Addendum
Outline changes to Dual Appointment Agreement (Any changes that affect compensation details or
employee obligations require a new agreement to be executed and routed through the approval
workflow)
Dual Appointment Coordinator Signatures
Requesting Institution DAC
Date
Signature
Home Institution DAC
Date
Signature
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signature
click to edit
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signature
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Dual Appointment Agreement
Last Revision: 06/21/2016
9
Appendix D – Dual Appointment Verification of Work
Employee Name
Home Institution
Requesting Institution
Dates of Service
The signatures below certify that the employee is currently performing or has performed the services
agreed upon in the attached Dual Appointment Agreement between the above dates of service to the
satisfaction of the Requesting Institution. The signatures also affirm that the services are expected to
continue as applicable.
Requesting Institution DAC
Date
Signature
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signature
click to edit
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Section A Preliminary Approval of Dual Appointment Engagement (Darton State College)

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Completed 25 July 2020

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