University of Wisconsin System
Unclassified Staff (Faculty, Academic Staff and Limited Appointees) Report on Outside Activities and Interests
(as required under Section UWS8.025 Wisconsin Administrative Code)
Name Department/Unit
Faculty Academic Staff Limited Percent University Appointment
Signature
Please read the Guidelines for Reporting Outside Activities on the attachment and fill in the required information below. Completed
forms should be forwarded to your department chair or unit director.
I have read the Guidelines and do not have any remunerative outside activities in my field of interest to report. (If you check this
box, forward the signed form to your chair/director.)
A. Remunerative Relationships
I have received net remuneration for professional outside activities in my field of professional interest (e.g., consulting, research,
teaching, writing, etc.). List below the name of the organization or business, type of activity (e.g., consulting, teaching, etc.) and
the aggregate amount of time spent (days) in the activity, and whether you received $5000 or more from a single source.
Check if $5000
Name of Business* Time Spent or More From a
or Organization Type of Activity (days) Single Source
_________________________________ _________________________________ _________________ __________________
_________________________________ _________________________________ _________________ __________________
_________________________________ _________________________________ _________________ __________________
*If you believe that you should not publicly identify the name of the organization, you must receive approval from your dean, as
indicated by the dean’s signature below (e.g., if revealing the name would be damaging to the organization’s legitimate
competitive interests).
I have received compensation from a nongovernmental sponsor of university research, teaching, or training for which I am a
principal investigator.
Name of sponsor: _________________________________________________________________________________________
B. Offices and Directorships
Identify below any business or other organization related to your field of academic interest or professional specialization for
which you or your immediate family served as an officer, director, or trustee. No identification need be made of professional
societies, trusts, or charitable, religious, social, community service, or political organizations.
Name of Business/Organization City and State Position Held
____________________________________________ ________________________________ ________________________
____________________________________________ ________________________________ ________________________
____________________________________________ ________________________________ ________________________
C. Ownership Interests
List below any business or other organization related to your field in which you or your immediate family individually, or in
aggregate, owned or controlled at least 10% of the outstanding equity.
Name of Business/Organization City and State
_______________________________________________________________ ______________________________________
_______________________________________________________________ ______________________________________
_______________________________________________________________ ______________________________________
I have reviewed the information itemized above:
Signature of Chair/Director
Signature of Dean Designee_______________________________________________________________________________________
Print
2012
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