Request For Ethics Approval To Engage In Outside Work Or Activity - United States Department Of The Interior Page 2
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2C. Certifications: Questions or requests for guidance should be directed to your servicing Ethics Office.
ALL questions below must be answered with a Yes or No.
17. I understand that participating in an official matter (including providing
Yes
No
recommendations or advice) that could directly affect the financial interests of the outside
entity, company, State/local government, individual, or organization could violate 18
U.S.C. § 208, a criminal conflict of interest ethics statute.
18. I understand that I must disqualify (recuse) myself from participation in official matters
Yes
No
that could directly affect the financial interests of, or give the appearance of a lack of
impartiality toward, the outside entity, company, State/local government, individual, or
organization for which I will perform the outside work or activity. If the outside work or
activity prevents me from accomplishing my Federal job, I understand I may be required to
stop the outside work or activity.
19.
Yes
No
I understand that 18 U.S.C. §§ 203 and 205 generally prohibit a Federal employee from
outside entity, company, State/local government, individual, or organization
representing an
before any Federal agency, court or officer.
20. I will be in a non-duty or authorized leave status when I perform the outside work or
Yes
No
activity.
21. I will not use any Government facilities, equipment, or supplies in furtherance of the
Yes
No
outside employment or activity except as authorized by DOI Limited Personal Use policies.
22. I will not use or disclose any nonpublic information as part of this outside work or
Yes
No
activity.
23. I will neither use, nor permit others to use, my official title or position in conjunction
Yes
No
with the outside work or activity except as permitted by 5 C.F.R. 2635.807(b).
24. If there is a significant change in the nature or extent of my outside work or activity, or
Yes
No
in my official duties with DOI, I will submit a revised request for approval to engage in
outside work or activity
25. I understand that approval to engage in outside work or activity does not relieve me of
Yes
No
my obligation to comply with all applicable laws and regulations governing employee
conduct and ethics.
Signature of Employee:
Date:
D. Supervisor Recommendation to the Ethics Office
I recommend approval.
Remarks:
(Attach additional information if necessary)
I recommend disapproval.
Date:
Supervisor Signature:
Telephone:
Supervisor Name: (PLEASE PRINT)
(
)
E. Ethics Office
Action
Remarks:
(Attach additional information if necessary)
Approved
Disapproved
Date:
Signature:
Ethics Official or Ethics Counselor Name:
Position:
Distribution: Original retained at servicing Ethics Office and copy to employee. A signed fax
copy, a
scanned copy, or an electronically signed document
is acceptable as an original.
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