SC ETHICS ACT DISCLOSURE FORM Name of Faculty Member: Title:

SC ETHICS ACT DISCLOSURE FORM
Name of Faculty Member:
__________________________________________
Title:
__________________________________________
Department/College:
__________________________________________
Name of textbook or other course
materials to be assigned:
__________________________________________
Name of course(s) in which these
materials will be assigned:
__________________________________________
# of students enrolled in course(s):
__________________________________________
Semester(s) for which
authorization is sought:
__________________________________________
Anticipated amount of royalties &/or
other income from these materials: __________________________________________
In compliance with the SC Ethics Act, I hereby request approval by my Department
Chair (or Dean) to assign the above-named materials, which I deem pedagogically
appropriate for the specified course(s).
Signature of Faculty Member:
_________________________________________
Date:
_________________________________________
Approved:
_________________________________________
Department Chair (or Dean)
Date:
_________________________________________