DECLARATION OF OUTSIDE COMPENSATED SERVICES (ADMINISTRATIVE FACULTY) Employee Name: Please indicate whether you are: Full Time: Part Time: CSN Department and Phone #: Name of immediate supervisor: Name of Vice President: Section I. 1. Do you currently perform scholarly or professional outside compensated work as defined on page 3? No Yes If you answered please complete the remainder of this form and submit to your supervisor. If “yes” you answered please skip Section II and complete Sections III and IV. “no” 2. Do you intend to perform scholarly or professional outside compensated work as defined on page 3? No Yes If you answered please complete the remainder of this form and submit to your supervisor at “yes” least 10 days in advance. If you answered to this question, please skip Section II and complete “no” Sections III and IV. Section II. 3. Company/Organization for which outside work will be performed: 4. Nature of intended work: Does this outside work present any potential conflict of interest for CSN, as defined on page 3? 5. No Yes Immediate Supervisor: Concur Do Not Concur Signature: ______________________
DECLARATION OF OUTSIDE COMPENSATED SERVICES (ADMINISTRATIVE FACULTY) Employee Name: Please indicate whether you are: Full Time: Part Time: CSN Department and Phone #: Name of immediate supervisor: Name of Vice President: Section I. 1. Do you currently perform scholarly or professional outside compensated work as defined on page 3? No Yes If you answered “yes” please complete the remainder of this form and submit to your supervisor. If you answered “no” please skip Section II and complete Sections III and IV. 2. Do you intend to perform scholarly or professional outside compensated work as defined on page 3? No Yes If you answered “yes” please complete the remainder of this form and submit to your supervisor at least 10 days in advance. If you answered “no” to this question, please skip Section II and complete Sections III and IV. Section II. 3. Company/Organization for which outside work will be performed: 4. 5. Nature of intended work: Does this outside work present any potential conflict of interest for CSN, as defined on page 3? No Yes Immediate Supervisor: Concur Do Not Concur Signature: ______________________
declaration_of_oustide_compensated_administrative_faculty.docx