Request For Ethics Approval To Engage In Outside Work Or Activity - United States Department Of The Interior

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DI –
United States Department of the Interior
Dec 2007
Request For Ethics Approval to Engage in Outside Work or Activity
Approval of the Departmental Ethics Office or an ethics counselor from your bureau is required prior to
engaging in outside work or activity (paid or unpaid) that is: 1) related to a DOI employee's job duties or
the mission of the DOI; 2) performed for a prohibited source,* as defined in 5 C.F.R. 3501.105; or 3)
performed for an outside entity (for example, a company, state/local government, individual, or
organization) whose interests are related to the Department.
A request to engage in outside work or activity will not be approved if it would:
reate a conflict of interest with the employee’s official job duties;
c
a)
v
b)
iolate the Standards of Ethical Conduct for Employees of the Executive Branch, 5 C.F.R. Part 2635; or
v
c)
iolate a Federal ethics statute or regulation.
A. Federal Employment Information
(PLEASE PRINT)
1. Last Name, First Name, MI:
2. Grade:
3. Telephone:
4. FAX:
(
)
(
)
5. E-mail address:
6. Position / Title:
7. Office Name and Address:
8. Job duties (attach position description or additional information, if needed):
B. Information about Prospective Outside Work or Activity
(PLEASE PRINT)
9. Name of outside entity, company, State/local government, individual, or organization:
10. Address:
11. Telephone:
(
)
12. Salary or compensation: (if unpaid, indicate “None”)
13. Hours per week:
14. Start date:
15. Expected end date:
16. Describe the proposed outside work or activity:
(Attach additional information if necessary)
* Prohibited source generally includes any outside entity or individual who: (1) is seeking official action by an
employee’s bureau or the Department; (2) does business or seeks to do business with an employee’s bureau or
the Department; (3) conducts activities regulated by an employee’s bureau or the Department; (4) has interests
that may be substantially affected by the performance or nonperformance of the employee’s official duties; or (5)
is an organization a majority of whose members are described in (1) through (4) above.

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