Fillable WIDELY ATTENDED GATHERING REQUEST FORM EVENT INFORMATION (Uniformed Services University Maryland)

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WIDELY ATTENDED GATHERING REQUEST FORM EVENT INFORMATION (Uniformed Services University Maryland)

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  • 17 check-boxes
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WIDELY ATTENDED GATHERING REQUEST FORM
Invitee’s Name:
Invitee’s Phone:
Invitee’s Department:
Invitee’s Position:
Invitee’s E-mail:
Admin POC Name:
EVENT INFORMATION
Name of Event:
Sponsor(s) or Organizer(s) of Event:
Date of Event:
Location of Event:
Nature and Purpose of Event:
Approx. Number of Attendees:
Identify General Sources of Attendees: (check all that apply)
Federal Executive Branch State/Local Government
DoD Academia
Non-DoD Industry
Federal Legislative Branch Other (describe)
Is an entity other than the
event sponsor paying the cost for the invitee?
No
Yes Identify Entity
Does the invitation include an unsolicited offer for the employee to bring a guest?
No
Yes How many?
Will other attendees also be accompanied by a guest? No Yes
Does the invitation include an unsolicited offer for the employee to bring a guest?
Does the person / organization extending the invitation have any matter(s) (collaborations with or
otherwise doing business with USU or DoD) pending before
USU or DoD and, if so, is the invitee involved in these matters? No Yes
Estimated cost per person of food, refreshments and entertainment. $
If different from value listed above, list cost of
admission fee. $
In addition to free attendance, are other gifts offered (e.g., free parking,
memento, etc.).
No
Yes List & Estimate Cost
Is the sponsoring or inviting organization tax-exempt under 501(c)(3)? No
Yes
**Please include copy of invitation with request.
Is any portion of travel costs being covered or offered as part of offer? No Yes
If yes, please list the travel items being covered and their value (estimate cost if necessary) in $
values:
OGC Form 3
WAG
Requester Name
Signature
Date
To the best of my knowledge, accepting the offer of attendance does not present a conflict of interest, i.e.,
a reasonable person with knowledge of all of the facts would not question the integrity of USU programs or
operations.
This request is made with full knowledge of applicable USU policies regarding travel, local travel, and gift
acceptance. I understand that before I accept the offered free attendance and other expenses related to attendance
that I must first be approved by my supervisor and an Ethics Official.
By signing this request, I confirm that all the information I have provided is true and accurate to the best of my
knowledge.
_____________________________
_______________________________
________________________
Submit form to OGC, A1030, or electronically to ethics@usuhs.edu
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SAMPLE AUTHORIZATION FORM
This form must be completed by the first supervisor in the employee’s chain of command
who is either: (a) a commissioned military officer or (b) a civilian (not a contractor) above
the grade of GS-11.
MEMORANDUM FOR RECORD
SUBJECT: Written Authorization to Accept Free Attendance at a Widely Attended Gathering
has been invited by
to attend
on in at no charge.
.
is a Federal employee assigned as
in the Dept. The offer of free attendance does doesn’t
include an invitation for the employee to bring a guest. The event will be attended by approximately
people from (check all that apply) government , industry , academia ,
other (name all that apply)
The attendees represent a diversity of views or interests. There will be an opportunity for the USU employee to
exchange ideas and views with other attendees. As a result, I find that the event is a widely attended gathering;
the employee’s attendance is in the agency’s interest because attendance will further agency programs or
operations; and the agency’s interest in the employee’s attendance outweighs the concern that the employee
may be, or may appear to be, improperly influenced in the performance of official duties.
I have considered the importance of the event to the agency, the nature and sensitivity of any pending matter
affecting the interests of above-referenced non-Federal source and the significance of the employee’s role in
any such matter. I have also considered the purpose of the event, the identity of other expected participants,
the value of the gift of free attendance, whether acceptance would reasonably create the appearance that the
non-Federal source is receiving preferential treatment, and whether persons with views or interests that differ
from those of the non-Federal source have been, or would be, provided similar access to Government
employees.
Acceptance of this offer of free attendance is approved, subject to review and concurrence by the University’s
ethics official. This memorandum must be coordinated with the Office of General Counsel prior to acceptance.
_______________________________ ___________________________________ _________________
SUPERVISOR NAME SIGNATURE DATE
_______________________________ ___________________________________ __________________
ETHICS OFFICIAL NAME SIGNATURE DATE
Copy to:
** Employee’s should retain a copy of this memo for six years.
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WIDELY ATTENDED GATHERING REQUEST FORM EVENT INFORMATION (Uniformed Services University Maryland)

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Completed 28 August 2020

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