ࡱ> lnki )bjbjښ vt\\!$4444P4ddddd?Y e$n!$$l;m??mm;ddPm ddm:dRzw }.f0 $$$8mmmmmmm;;mmmmmmm$mmmmmmmmm> : PM-11 FORM A Disclosure of Outside Employment (For FY 20___ - 20___) Louisiana State University of Alexandria Louisiana State University Presidential Memorandum Number 11 requires that all full-time employees of the LSU System comply with its provisions and disclose all outside employment as defined within it. Completion of Form A is required for each outside employment event; blanket approvals will not be granted. If the approval of the Chancellor or President is required, Form B must also be attached. Employees are required to become familiar with PM-11 before completing this form. EMPLOYEE DISCLOSURE 1. Employee Name:  3. Name of outside employer or business: 2. Department:  4. Time commitment required: 5. Describe proposed activity below: If no outside employment is contemplated or currently engaged write NONE in this section, then complete lines 7 through 11 and forward this form to your next supervisory level. If the answer is YES to any of the questions (6A-F or 13A-D) further detailed information will be required. For a YES response the Chancellor and/or the LSU President may be required to signify final action.  6A. My outside employment would be with an entity currently doing or actively seeking to do business with my unit at the University. [ ] Yes [ ] No 6D. I am collaborating with or on special assignment to a unit within the University with which the company is doing or is seeking to do business. [ ] Yes [ ] No 6B. My outside employment would involve teaching, which results in university level credit, will be conducted on University time or will utilize University property or services. [ ] Yes [ ] No 6E. My outside employment would yield results which advance a theory or practice in my field. [ ] Yes [ ] No 6C. My outside employment would involve my providing professional, personal, consulting and social services to a department, commission, council, board, office, bureau, committee, institution, agency, government, corporation, or any other establishment of the Executive Branch of the State of Louisiana. (President's Approval Required) [ ] Yes [ ] No 6F. My outside employment would result in my receiving compensation to assist in the passage or defeat of state legislation during the fiscal year in which the legislation was pending in the legislature. [ ] Yes [ ] No I will explain to the proposed outside employer that: (1) I do not represent said outside employer as an employee of the University in any manner, (2) any views I express on behalf of an outside employer do not necessarily reflect the view of the University, and (3) in no way may the name of the University nor my official University capacity be used in support of any position I may take on behalf of said outside employer. Furthermore, I certify that University personnel, laboratories and equipment will not be used in connection with outside employment other than as provide in PM-11. My signature attests to my understanding of and compliance with P.M.-11. 7. Name:  8. Title: 9. Signature:  10. Department: 11. Date:   ADMINISTRATIVE REVIEW Circle the number corresponding to any employee responses with which you disagree. Department Chair [A] [B] [C] [D] [E] [F] Dean 6: [A] [B] [C] [D] [E] [F] Vice Chancellor [A] [B] [C] [D] [E] [F] Indicate your agreement or disagreement with the following statements. 13A. The proposed duties ordinarily would be performed as part of the public service portion of the employees duties and responsibilities. Department Chair [ ] Yes [ ] No Dean [ ] Yes [ ] No Vice chancellor [ ] Yes [ ] No 13B. The proposed activity more appropriately would be accomplished by a contract through the university. Department Chair [ ] Yes [ ] No Dean [ ] Yes [ ] No Vice Chancellor [ ] Yes [ ] No 13C. The legal entity for which the outside employment is proposed has substantial economic interest which may be materially affected by the way in which the employee performs his or her duties and responsibilities as a University employee. Department Chair [ ] Yes [ ] No Dean [ ] Yes [ ] No Vice Chancellor [ ] Yes [ ] No 13D. The outside employment involves public policy. (Presidents Approval Required) Department Chair [ ] Yes [ ] No Dean [ ] Yes [ ] No Vice Chancellor [ ] Yes [ ] No ADMINISTRATIVE APPROVALS If the answer is YES to either question (6C) or 13(D), the Presidents approval is required. All forms must be approved by the appropriate Vice-Chancellor and the Chancellor [ ] RECOMMENDED [ ] NOT RECOMMENDED Signature: Direct Supervisor Date [ ] RECOMMENDED [ ] NOT RECOMMENDED Signature: Dean or Department Director Date   [ ] APPROVED [ ] DISAPPROVED [ ] Forwarded thru Chancellor for action by President [ ] Returned to employee for compliance with P.M.-11 requirement requiring approval of Chancellor Signature: Provost / Vice Chancellor Date All reviewing administrators hereby certify that they have read and are familiar with the Louisiana Code of Governmental Ethics and the approval of this outside employment does not knowingly violate the Code of Ethics, PM-11 or any other rule or regulation of the University. PM-11 FORM B Disclosure of Outside Employment Requiring Approval by the Chancellor or President Louisiana State University of Alexandria If outside employment requires approval by the Chancellor or the President, the employee must follow the certification and contractual provisions of PM-11 under the Approval Level section for outside employment. All required documents shall be attached to and made part of this Disclosure Form before submission through administrative channels for review by the chancellor. The following approvals must be obtained before engaging in the proposed outside employment. EMPLOYEE DISCLOSURE  Employee's Name: Proposed outside employer or business: Amount of Proposed Compensation: Date:  APPROVAL/CERTIFICATION BY CHANCELLOR The outside employment activities are not within the course and scope of the employee's duties to the University for which the employee is being compensated by the University. The outside employment activities do not conflict, delay or in any manner interfere with instructional, scholarly and/or services which the employee is obligated to perform for the University. The consulting activities to be performed are within the academic or professional discipline of the employee or are related to the areas of expertise in which the employee is employed by the University. Signature: Chancellor Date Louisiana State University of Alexandria  OUTSIDE EMPLOYMENT INVOLVING PUBLIC POLICY OR A STATE AGENCY [ ] APPROVED [ ] NOT APPROVED  Signature: President Date:   -DEM`bmnoT W j F J ' * FHg^?BD翵矏tbVhkCJOJQJaJ"hk56CJOJQJ\]aJhk6CJOJQJ]aJhz4CJOJQJaJhk5>*CJOJQJ\aJhkCJOJQJaJhNOJQJaJhsWOJQJaJhkOJQJaJh;5CJOJQJ\aJhk5CJOJQJ\aJhkCJOJQJhk5CJ$OJQJ\aJ$! 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