Non-Employee Affiliate Request Form
Non-Employee Affiliate Request Form
To be completed by faculty member requesting Non-Employee Affiliation
This Request is: __ __ New __ _ Renewal
Instructions: A Non-Employee Affiliate (NEA) is an individual approved to conduct research related business on the Clark University campus on a regular basis over a fixed and limited period of time in a capacity that does not include appointment, pay or student status. A supervising faculty member and the individual requiring NEA status should complete the following forms, sign and date them, and return them with a copy of the NEA’s resume/CV to the Office of Sponsored Programs and Research for review and approval by the Dean of Research. The supervising faculty member’s department and the NEA should retain copies of these forms. The supervising faculty member will be contacted once approval has been granted. At that time the NEA will be required to obtain a Non-Employee Affiliate picture ID from Clark’s ID Office and the ID will be activated by the Campus Police for access to approved buildings. Please review Procedures for Requesting Non-Employee Affiliate Status for further information and contact the Office of Sponsored Programs and Research at u with any questions.
Non-Employee Affiliate Name: ______
Supervising Faculty Member Name: ______
Department: ______
Start Date: ______
End Date: ______
(Note: Non-Employee Affiliations may be for up to 24 months and may be renewable at expiration.)
Describe briefly the work to be performed by the above Non-Employee Affiliate:
Click here to enter text.
Please note where the activities of the above Non-Employee Affiliate will be performed including all buildings, classrooms, and/or laboratory spaces to which the Non-Employee Affiliate will require access:
Click here to enter text.
Will the Non-Employee Affiliate require guest access to University computing resources?
☐ Yes ☐ No
If yes, what resources will the NEA need? (check all that apply and provide additional info as indicated)
☐Clark Network with personal computer
Indicate MAC Ethernet Address: Click here to enter text.
☐Clark computers only
☐Clark wireless network
☐Existing mailboxes
Indicate mailbox: Click here to enter text.
Will this person need to send email from this account? ☐ Yes ☐ No
☐Existing file shares
Indicate server & share (e.g. \\fs.clarku.edu\dept\xxxx): Click here to enter text.
Permissions: ☐Read Only ☐Full
☐Existing web folder
Indicate web folder (e.g. www.clarku.edu/offices/xxxx): Click here to enter text.
☐Personal file share (a file share for their exclusive use)
A Non-Employee Affiliate is not eligible to receive an @clarku.edu email address.
______
Supervising Faculty Member Signature Date
______
Department Chair/Institute Director Signature Date
Approved By:
______
Dean of Research Date
To be completed by Non-Employee Affiliate
Non-Employee Affiliate Information
Name: Click here to enter text.
Home Street Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text.
DOB: Click here to enter text.
Emergency Contact and Relationship: Click here to enter text.
Emergency Contact Phone: Click here to enter text.
Non-Employee Affiliate Employer Information
Place of Employment: Click here to enter text.
Title: Click here to enter text.
Employer Address: Click here to enter text.
City, State, Zip: Click here to enter text.
Employer Phone: Click here to enter text.
Supervisor’s Name and Title: Click here to enter text.
I hereby confirm that the above information is correct. Additionally, I understand that I am not an employee of Clark University and therefore I am not entitled to compensation; benefits of any kind including, but not limited to, workers’ compensation, unemployment compensation or health insurance; and employee privileges including, but not limited to, access to library and athletic facilities, and employee discounts with area businesses and organizations. I agree to review and abide by all Clark University policies and procedures and further agree that any violations of said policies or procedures shall result in the immediate revocation of my Non-Employee Affiliation status. I understand that I am required to notify Clark University when I no longer require my Non-Employee Affiliation and to return any identification card(s), keys, and/or other Clark property issued to me as part of my Non-Employee Affiliation.
Signed: ______Date: ______
For Internal Use:
ID Number: ______
Copies Provided to:
1. Business Manager/ID Office _____
2. Campus Police _____
3. ITS _____
4. Supervising Faculty Member _____
5. Supervising Department/Institute _____
6. OSPR NEA Files _____
Non-Employee Affiliate’s ID Card to Be Activated for Access to the Following Buildings (as approved above):
______
______
______
______
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