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UNIVERSITY OF WEST FLORIDA

OUTSIDE ACTIVITY AND CONFLICT OF INTEREST FORM

In general, employees of the University of West Florida are permitted to engage in outside

activities. The University of West Florida Conflict of Interest Policy, AC-11.02-05/13 (“the

Policy” https://nautical.uwf.edu/unitapp/publication/Pub.cfm?PubFormatID=1152 ), provides

guidance to employees seeking to engage in outside activities. In accordance with the Policy,

employees are required to report their outside activities to the University and obtain approval to

participate in these activities prior to engaging in them.

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Outside activities are those activities,

whether compensated or not, which are not part of the employee’s assigned duties and for which

the University has provided no compensation.

A conflict of interest arises when an individual’s private interests (such as outside professional or

financial relationships) might interfere with his or her professional obligations to the University of

West Florida. Such situations do not necessarily imply wrong-doing or inappropriate activities.

However in a university setting, they can compromise, or be perceived as compromising,

important academic values, research integrity, or the University’s mission. This mandates that

such conflicts or potential conflicts be disclosed and then managed, mitigated or eliminated.

All employees, including student employees and OPS employees (“employee(s)”) engaging in

outside activities requiring disclosure must complete this Outside Activity and Conflict of Interest

form.

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WHEN MUST A FORM BE SUBMITTED?

An Outside Activity and Conflict of Interest form must be submitted,

• Each time an employee plans to engage in a new activity requiring disclosure,

• At the beginning of each academic year for activities of a continuing nature (therefore, for

continuing activities, the form is only valid through August 7 of each year), and

• Any time there is a significant change in an activity which has previously been reported.

WHAT ACTIVITIES REQUIRE DISCLOSURE?

All employees, including those on compensated leave or approved leave of absence (which

includes professional development leaves, sabbaticals, annual leave, sick leave, etc.), must submit

a disclosure of outside activity on this form if, during employment with the University of West

Florida, any of the following will occur:

1. The employee seeks to engage in any compensated activity which is not part of the

employee’s assigned duties,

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2. The employee seeks to engage in any outside activity, whether compensated or not, which

the employee should reasonably conclude

(a) may create or reasonably appears to create a conflict of interest;

(b) may otherwise interfere or reasonably appears to interfere with the full performance of

the employee’s professional responsibilities or other institutional obligations; OR,

(c) may create conflict of time, which is defined as an outside activity (including

consulting, public service or pro bono work) which interferes with the employee’s

primary commitment of time, attention and intellectual energies to the University.

3. The employee is engaged to teach or is otherwise employed at another educational

institution.

Activities which are performed wholly during a period in which the employee has no appointment

with the University need not be reported, however, employees are encouraged to report activities

during such periods.

Please review the non-exhaustive list of types of outside activities which must be reported and for

which prior approval in writing is required in the Conflict of Interest Policy (AC-11.02-05/13 at

the following link: https://nautical.uwf.edu/UnitApp/Publication/Pub.cfm?PubFormatID=1152).

An employee’s failure to fully and properly report outside activities and other interests or failure to

follow any conditions imposed pursuant to the University’s approval of such activities, may be

grounds for disciplinary action, up to and including dismissal.

Please use a separate form for each activity or interest.

1. Employee Name: ________________________________________________

2. Department/Division/Unit: _________________________________________

3. Name of Proposed Employer, Contracting Entity, Business, etc., Address and Contact

Information: ____________________________________________________

4. Description of Activity and/or Interest including Job Title:

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5.

For researchers employed on a federal grant (including Principal Investigators, Co-

Investigators, Senior Key Personnel, OPS employees, and students), enter source, amount

and type of compensation (e.g., company, client, royalty, honorarium, in-kind

compensation, equity or other interest). Also list the previous amount of compensation

received from this source during the current contractual period.

6. Anticipated dates of activity: ____________________ to ____________________

7. Estimated number of hours per week, including travel time:

Time Devoted to Outside Activity

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

8 am to

5p.m.

5p.m. to 8

a.m.

All day

Total Number of Estimated Hours per week devoted to outside activity: __________

8. This activity will or will not interfere with my University obligations including but not

limited to teaching, research, service, advising, office hour obligations or administrative

duties or any other duties. If it will, please describe how you will complete your

obligations to the University and engage in the outside activity or interest.

9. Will University students or other University employees be involved with this activity?

Yes No

If yes, please state their names and a description of their roles in the activity.

10. Are you required, as a condition of the outside activity/interest, to waive any rights you or

the University of West Florida may have to intellectual property, including copyrights,

trademarks, patent rights, and/or proprietary information/trade secrets?

Yes No. If the answer to this question is yes, the Office of Research and

Sponsored Programs must review this form and approve the waiver of rights prior to

engaging in the activity.

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11. Will University equipment, facilities, services or other resources be used?

Yes No If yes, please complete and submit the Request for Approval of Use of

University Resources in Conjunction with Outside Activity form

(http://uwf.edu/academic/policies/conflict/Use_of_University_Resources_Form.pdf) with

this form.

12. Do you or an immediate family member have an interest in and/or an employment

contractual relationship with a business entity that is or might be doing business with the

University?

Yes No If yes, please provide the name of the business entity and the name of

the family indicating the relationship to you and the business entity.

NAME OF FAMILY MEMBER RELATIONSHIP BUSINESS ENTITY

__________________________ ______________ _________________

13. The total number of Outside Activity and Conflict of Interest forms submitted during the

period from August 8 to August 7th, including this form is _____. Estimated total number

of hours to be spent per week on all outside activities, interests, including this one is _____.

14. I request a conference with my immediate supervisor to discuss this request.

Yes No

I have read the University of West Florida Conflict of Interest Policy AC-11.02-05/13. The

proposed outside activity or employment reported herein does not and will not interfere with the

full performance of my professional duties, institutional responsibilities or any other obligations I

may have to the University of West Florida and does not create a conflict of interest.

I certify that I have provided complete and accurate information on this form. I understand that

any approval of an outside activity or conflict of interest that is based upon an incomplete or

inaccurate report by me is null and void.

Employee Signature ______________________________________ Date______________

Typed/Printed Name: _____________________________________

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Chair/Director/Supervisor Review:

I recommend this request be: ____ Approved ____ Disapproved Comments:

_____________________________________________________________________________

Chair/Director/Supervisor Signature: _____________________________ Date______________

Typed/Printed Name: _________________________________________

Dean/AVP/Department Head Review:

I recommend this request be: ____ Approved ____ Disapproved Comments:

_____________________________________________________________________________

Dean/AVP/Department Head Signature: ___________________________ Date_____________

Typed/Printed Name: __________________________________________

Office of Sponsored Research Review/Notes: Date_____________

_____________________________________________________________________________

President/Vice President’s Determination:

____ Approved ____ Disapproved Comments:

_____________________________________________________________________________

President/Vice President’s Signature: ______________________________ Date____________

Typed/Printed Name: __________________________________________

Human Resources Review/Notes:

_____________________________________________________________________________

Date filed in Human Resources employee personnel file: __________________

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