Request for Approval of Outside Activity

REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY

Note to Employee: See Information on Reverse Side of This Form

1.NAME(Last, First, Initial) / 2.DEPARTMENT/ACTIVITY
3. TITLE OR POSITION / 4. GRADE OR RANK
5. NAME, ADDRESS AND BUSINESS OF PERSON OR ORGANIZATION FOR WHOM OUTSIDE SERVICES WILL BE PERFORMED/SELF-EMPLOYMENT / 6. LOCATION WHERE SERVICES WILL BE PERFORMED
7. NATURE OF ACTIVITY (Indicate type of activity, e.g., teaching, consultative services, etc., and give full description of specific duties or services to be performed. Specify, when possible, the scheduled days of week and hours or day proposed activity will be performed.)
8.ESTIMATEDTIMEINVOLVEDINOUTSIDEACTIVITY
a. PERIOD COVERED
FROMTO / b.ESTIMATEDTOTALTIMEDEVOTEDTOACTIVITY(Ifona continuingbasis,giveestimatedtimeperyear)
c.WILLWORKBEPERFORMEDENTIRELYOUTSIDE USUALWORKINGHOURS?
YES NOIF NO, INDICATE ESTIMATED NUMBER OF HOURS OR DAYS ABSENT FROM WORK
9. DO YOUR OFFICIAL DUTIES RELATE IN ANY WAY TO THE PROPOSED ACTIVITY?
YES NO (DESCRIBE)
10.IF PROVIDING CONSULTATIVE OR PROFESSIONAL SERVICES, ARE YOUR WOULD BE ASSOCIATES RECEIVING OR WILL THEY SEEKA GRANT OR CONTRACT FROMA FEDERAL AGENCY?
YES NO(DESCRIBE)
11. METHOD OR BASIS OF COMPENSATION
FEE HONORARIUM PER DIEM PER ANNUM
ROYALTY EXPENSES OTHER: / 12.WILLCOMPENSATIONBEDERIVEDFROMA GOVERNMENTGRANTORCONTRACT?
NOYES(DESCRIBE)
13.THISREQUESTISMADEWITHTHEFULLKNOWLEDGEOFDEPARTMENTANDPRINCIPALOPERATINGCOMPONENT POLICYANDPROCEDURESONOUTSIDEACTIVITIES. THESTATEMENTSIHAVEMADEARETRUE,COMPLETEAND CORRECTTOTHEBESTOFMYKNOWLEDGEANDBELIEF.
14.SIGNATURE15.DATE / 16.ADDITIONALINFORMATIONATTACHED
YESNO
17.ACTIONRECOMMENDED(Department Chair/Head AND Brigade Commander for Military Officers)
a. APPROVAL
DISAPPROVAL / b.SIGNATURE / c.TITLE / d.DATE
a. APPROVAL
DISAPPROVAL / b.SIGNATURE (BDE CMD) / c.TITLE / d.DATE
18.ACTION TAKEN (President or Dean for Civilian Employees and Military Officers ORBrigade Commander for Enlisted Members)
a. APPROVAL
DISAPPROVAL / b.SIGNATURE / c. TITLE / d.DATE

REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY USUHS FORM 1004

TheDepartmentof Defenseis requiredbythePrivacyActof 1974 to disclosethefollowinginformationto youprior to yourcompletingtheattachedUSUHSForm 1004.

Therefore,in accordancewithSection3(e)(3)of P.L.93-579(thePrivacyActof 1974) youareadvisedthat:

1.ExecutiveOrder12674authorizestheDepartmentofDefensetocollecttheinformation requestedonthisform.

2.Theinformationdisclosedbyyouonthisformwillbeused inconsideringyourrequestto determinewhethera conflictofinterestwouldexist betweentheoutsideactivityandyourofficial duties.

3.Theinformationsuppliedbyyouwillbetreatedas Confidentialandmadeavailableonlyto specificallyauthorizedpersons.

4.Your disclosureof theinformationrequestedonthisform is voluntary. However,your failureto providetheinformationrequestedonthisform willprecludeapprovaloftheoutsideactivity.

SignatureDate

INSTRUCTIONS

Item5-Self-Employment:If applicable,indicateself-employment,thetype of service(asmedical,legal,etc.),whether aloneorwithpartners,givingtheir names,and,ifprovidingprofessionalservicestoalarge numberof clientsor patients,estimatethetotalnumberratherthanlistingthemseparately.

Item10-FederalGrantsorContractsInvolved:DescribetheFederalgrantsorcontracts(type, grantingofcontracting department,etc.).Fulldetailsmust beprovidedonanyaspectofprofessionalandconsultativeserviceswhichinvolves, directlyorindirectly,thepreparationof grant applications,contractproposals,programreports,andother material whicharedesignatedtobecomethesubjectofdealingsbetweeninstitutionsandgovernmentunitsandtheFederal Government.

Item16-Attachments:Besureto signcopiesof allattachmentssubmitted.

Item17-COMMENTSOFRECOMMENDINGOFFICIAL:

Item18-REASONFORDISAPPROVAL: