REQUEST FOR APPROVAL by n39Jh3bO

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									                       REQUEST FOR APPROVAL
     OF EXTERNAL PROFESSIONAL COMMITMENT OR OUTSIDE EMPLOYMENT

 INSTRUCTIONS: This form is to be used by all University of Arizona employees to obtain approval
 PRIOR to entering into any external professional commitments or outside employment as required in the
 University’s policy on “Conflict of Commitment, External Professional Activities and Outside Employment”
 (see http://orcr.arizona.edu/coi/uapol/commitment).
                           The completed form should be submitted for approval
                          at least four (4) weeks prior to making the commitment.

 Employee Name:                                            Department:


 Title or Rank:                                            E-mail address:


 Entity to which the commitment for proposed external professional activity or outside employment would
 be made [name and legal status]:




 Description of proposed commitment for external professional activity or outside employment, including
 role, title, activity, location, purpose:



 Dates between which external professional                 Amount of time and schedule for performance of
 commitment would be performed [approval not to            the external professional commitment:
 exceed one year except in special circumstances
 requiring a longer commitment]:                              Amount of time:

     From:                                                    Schedule:

     To:


 Is there any relationship between your institutional responsibilities and the entity to         No      Yes
 which you propose to make the external commitment? For example, is the external
 entity a sponsor of any of your research? An entity with a licensing agreement for any
 of your intellectual property? Donor to your programs? Sponsor of internships for your
 students? Other?
 If yes, please explain the relationship:



 In performing this external professional commitment, will any University facilities or          No      Yes
 resources (including space, personnel, equipment, etc.) be used?
 If yes, please indicate how:




University of Arizona – Office of Research Compliance and Policy                           coc-request:20120824
 REQUEST FOR APPROVAL
 OF EXTERNAL PROFESSIONAL COMMITMENT OR OUTSIDE EMPLOYMENT


 Will any UA graduate or undergraduate students or postdoctoral scholars or other UA             No       Yes
 trainees be involved?
 If yes, list the individuals by name and indicate how they will be involved:



 How will your responsibilities be covered in your absence?



 Will you appear in legal proceedings or public hearings as a result of this work?               No       Yes

 What type and amount of compensation will you receive for your work (dollar range, equity, options,
 etc.)?




 I have read the University of Arizona Policy on Conflict of Commitment, External Professional Activities
 and Outside Employment (http://orcr.arizona.edu/coi/uapol/commitment) and the University Handbook for
 Appointed Personnel (UHAP 2.0606: http://uhap.arizona.edu/chapter_2#2.06.06) and any Departmental
 policies that may apply. I attest that this activity conforms to all University policies.

 Employee Name:

 Entity Name:

 Signature of Employee: ____________________________________               Date:


 Department or Unit Head:                                                       Approved        Not Approved

     Name (please type):                                                   Date:

     Signature: __________________________________________________



 Dean, Vice President, Provost or President, as appropriate:                    Approved        Not Approved

     Name (please type):                                                   Date:

     Signature: __________________________________________________

     PLEASE NOTE THE FOLLOWING:
      Your office will be the official Office of Record for this document, which must be maintained in
       accord with the University’s policies on personnel record retention. See University’s Records
       Management and Archives Division (http://rmaa.arizona.edu/).
      Please send a copy of the approved form to the University’s Conflict of Interest Program Office for
       inclusion in the university files relevant to potential financial conflicts of interest.




University of Arizona – Office of Research Compliance and Policy                           coc-request:20120824

								
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