Outside Employment Disclosure Form 3 2012

UNIVERSITYOF LOUISIANA AT LAFAYETTE
Disclosure of Outside Employment
In accordance with Louisiana Revised Statutes and policies of the University of Louisiana
System, each full-time employee of the University of Louisiana at Lafayette must report any
outside employment for which a salary, retainer, fee, or other form of remuneration is earned
during the time of employment at UL.
A separate disclosure form is required for each outside employment activity reported.
IF YOU OBTAIN OUTSIDE EMPLOYMENT AT ANY TIME THROUGHOUT THE
YEAR, YOU MUST SUBMIT AN ADDITIONAL DISCLOSURE FORM AT THAT
TIME.
If you have no outside employment, fill in the first section and check “do not have outside
employment,” sign and date the form on the signature line and forward to your supervisor.
If you have outside employment, fill in the form completely including the dates you work at the
outside employment and the times of the day during which you will be working for such outside
employer. Sign and forward to supervisor. Outside employment should not conflict with any
University of Louisiana at Lafayette assigned duties.
It is understood that: (1) you may not represent an outside employer as an employee of the
University, (2) any views you may express on behalf of an outside employer do not necessarily
reflect the views of the University, and (3) the name of the University and/or your official
capacity at the University cannot in any way be used in support of any position you may take on
behalf of the outside employer.
Supervisor/Department Heads: Sign and date all forms, indicate your approval or disapproval
for those with outside employment and forward the completed form to the appropriate Dean or
Vice President.
Deans: Sign and date all forms, indicate your approval or disapproval for those with outside
employment and forward completed form to appropriate Vice President.
Vice Presidents: Sign and date all forms, indicate your approval or disapproval for those with
outside employment. Forward those completed forms which require Presidential approval to the
President. In instances in which the employee is employed by an entity granting University level
credit for students, forward those forms to the Provost. In all instances in which Presidential
approval is required, those forms and accompanying documents shall be stored in a permanent
file for three years as designated by the President. All others shall be forwarded to Human
Resources.
07/01/____ through 06/30/____
UNIVERSITY OF LOUISIANA AT LAFAYETTE
Disclosure of Outside Employment
In accordance with Louisiana Revised Statues University of Louisiana System Policy FS-III.VII.-1, each full-time
employee of the University of Louisiana at Lafayette must report any outside employment for which a salary,
retainer, fee or other form of remuneration is earned during the time of employment at University of Louisiana at
Lafayette. WHILE THE UNIVERSITY SENDS OUT YEARLY REMINDERS, YOU ARE REQUIRED TO
SUBMIT A DISCLOSURE FORM ANYTIME THROUGHOUT THE YEAR IF YOU LATER OBTAIN
OUTSIDE EMPLOYMENT.
Employee Name: ____________________________________ Department: ______________________________
(Print Name)
Title: _____________________________________________
____ I DO NOT have outside employment
Choose One: Classified __ Unclassified __
______ I DO have outside employment
Name and Address of outside employment or business: ________________________________________________
_____________________________________________________________________________________________
Time Commitment
Inclusive Dates
Required: _____________________
of Activity: ____/____/____ - ___/___/____
1. Describe the proposed activity of the outside employment: ___________________________________________
_____________________________________________________________________________________________
2. Will this outside employment, combined with any other outside employment previously approved, prevent or
infringe upon the performance or regularly assigned UL Lafayette duties? _______________________
3. Will this outside employment entail the utilization of University facilities, equipment, materials, or involve other
University employees or students? _________________________________________________________________
If yes, please explain: ___________________________________________________________________________
4. Will this outside employment involve an entity currently doing or actively seeking to do business with your
University department or administrative unit? _____________
If yes, please explain:____________________________________________________________________________
5. Is this outside employment with any other governmental entity (local, state, federal)? ______________________
If yes, please explain: ___________________________________________________________________________
6. Is this outside employment with any other educational institution?______________________________________
If yes, please explain:____________________________________________________________________________
It is understood that: (1) you may not represent an outside employer as an employee of the University, (2) any
views you may express on behalf of an outside employer do not necessarily reflect the views of the University, and
(3) the name of the University and/or your official capacity at the University cannot in any way be used in support of
any position you may take on behalf of an outside employer.
It is further understood that you have familiarized yourself with the provisions of Louisiana Revised Statutes
42:1101 et seq. relative to outside employment, Louisiana Revised Statutes 42;61 et seq. relative to dual office
holding and the policies on these subjects as defined in faculty and staff handbooks.
Employee Signature: ____________________________ Date: ____________
Recommend Approval
Department Head/Supervisor: ____________________ Date: ____________
___Yes
____No
Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
Dean: _______________________________________ Date: ____________
___Yes
____No
Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
Vice President/President:_______________________ Date: ____________
___Yes
____No
Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
**All reviewing administrators hereby certify that they have read and are familiar with the Louisiana Code of Governmental Ethics at
http://wwwprd.doa.louisiana.gov/laservices/publicpages/servicedetail.cfm?service_id=2571 and that approval of this outside employment does
not knowingly violate the Code of Ethics, or other rule or policy of the University of Louisiana at Lafayette or University of Louisiana System.
Excerpt from University of Louisiana System Policy Number: FS-III.VII.-1
The Board of Supervisors for the University of Louisiana System recognizes a right of employees to engage in outside
employment, and as required by L.R.S. 42:1123(9), has established policies and procedures requiring that such outside
employment be disclosed and submitted for administrative review and approval.
A. All full-time employees of the System, including faculty, other academic, unclassified, and classified, are required to abide by
this policy at all times, including during regular and summer term and while on paid or unpaid leave.
B. Outside employment is defined as any non-University/College activity for which economic benefit is received, including but
not limited to:
1. Employment with any non-University employer.
2. Contracts to provide consulting, personal or professional services to non-University individuals or entities, including
publishing agreements or arrangements.
3. Self-employment or operation of a business.
C. Economic benefits include cash payments or such other non-cash economic benefit, e.g., share of profits, shares of stock,
equity participation, etc. as the employee and outside employer may agree; provided that such non-cash economic benefit
shall not have a present value significantly in excess of fair compensation for the services rendered. Compensation rates for
outside employment need not be related to University salary rates but should be negotiated fairly based on normal private
sector levels for similar services.
D. Outside employment shall be performed only outside of assigned working hours or responsibilities, or during a period of paid
or unpaid leave. During said sabbatical, special or educational leave, outside activities may be permitted only in exceptional
circumstances, and only in accordance with Board Rules and State Law.
E. Outside employment shall not conflict, delay, or in any manner interfere with instructional, scholarly and/or other services,
which the employee is obligated to render to the University.
OUTSIDE EMPLOYMENT THAT WILL BE CONSIDERED FOR APPROVAL
A. General consulting, other outside employment or business activities.
B. Serving as an expert witness in an area based upon the employee’s training and experience.
C. Consulting on a non-University research project. A University employee may be engaged as a consultant on a nonUniversity research project or projects conducted by an outside employer, provided the employee neither supervises nor
performs the research.
OUTSIDE EMPLOYMENT THAT WILL NOT BE APPROVED
A. A university employee may not receive compensation to assist in the passage or defeat of legislation during the fiscal year in
which the legislation is pending in the legislature, except from the Louisiana Legislature or any department, institute or
agency within the Legislative branch.
B. If the University employee supervises non-University research or performs the research, he/she is considered a participant or
a part of the outside research team rather than a consultant. In such instances, the employee may not be employed by, nor
contract directly with, the outside agency unless it is not feasible or practical to seek a contract through the University under
established procedures for sponsored research, as determined by the appropriate University President.
C. Blanket approvals for outside employment will not be granted.
D. Employment or contractual relationships, which are considered to be a violation of the Louisiana Code of Governmental
Ethics, will not be approved.
EMPLOYEE RESPONSIBILITIES
Full-time employees contemplating outside employment or currently engaged in outside employment shall:
A. Disclose outside employment in accordance with University of Louisiana System Policy FS-III.VII.-1, and procedures
established therefor.
B. Submit a list of all contract or other agreements between the University and the outside employer in which the employee is
involved on behalf of the University. Such a list is to include, to the extent the information is known to the employee, the
owners, directors, majority shareholders, or affiliates of the outside employer. Additional information about such contracts
may be required by the University upon request.
C. Provide notification to the outside employer that he/she accepts such employment as an individual, and not, in any manner, as
a representative of the University. It is recommended that employees do this by including with any oral testimony or written
reports, a statement to the effect that the views expressed are those of the employee and do not necessarily reflect the views
of the University. In no case may the individual concerned use the name of the University or his/her University affiliation,
title, or address officially in any other way in support of any position he/she may take. Biographical data, including a
statement of employment by the Board of Supervisors for the University of Louisiana System, may be included as
introductory material to written reports or orally in the case of the expert witness statements, but may not be incorporated
into the body of the written report.
D. Comply with any other provisions of University of Louisiana System Policy FS-III.VII.-1.
**For additional information, please review on Outside Employment online at http://www.ulsystem.net/ .