Form Apm 025 - Prior Approval Form For Outside Activities - Category 1
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1GENERAL UNIVERSITY POLICY REGARDING ACADEMIC APPOINTEES
APM – 025
Conflict of Commitment and Outside Activities of Faculty Members
APPENDIX B
PRIOR APPROVAL FORM
FOR OUTSIDE ACTIVITIES (CATEGORY I)
Name:__________________________________
Faculty Title:____________________________________________________
Last
First
M.I.
Academic- or Fiscal-Year Appointment: _____________________________
Department:_____________________________
College/School:__________________________________________________
For each Category I outside professional activity in which you wish to engage in outside professional activities, answer the following
questions. Attach separate sheets, if necessary.
Type of activity in which you will be involved:
Category I Activities
Executive/managerial role:_____
Salaried employee: _____
Outside teaching or research activity: _____
Other potential conflict of commitment: _____
General description of the business/agency/organization/group/individual:___________________________________________ _____
____________________________________________________________________________________________________________
Activities/products/services of entity described above:________________________________________________________________
Nature of your relationship to entity named above (check all that apply):
Founder/co-founder: _____
Owner: _____
Consultant: _____
Board member: _____
Salaried employee: _____
Stockholder/partnership interest: _____
Equity/royalty interest: _____
Other, please explain: _________________________________________________________
______________________________________________________________________________________________________
Description of the nature of your participation in this activity, including, if you wish, possible beneficial outcomes to areas of research,
industry, and public service:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Beginning/ending month/year you could be involved in this activity:__________________________
Fiscal year(s) for which seeking approval:_________________________ (Approvals are generally for one fiscal year but may be
granted for a longer term not to exceed five years. Compliance reports must be submitted annually.)
Estimated number of days = involvement during academic- or fiscal-year appointment:_____________
Will you be requesting a full- or part-time leave without pay while engaged in this activity?____________________
Approval granted through fiscal year
ending June 30, _____
Request denied: _____
______________________________
_________
Department Chair
Date
______________________________
_________
Dean
Date
____________________________________
______________________________
_________
Faculty Member Signature
Date
Chancellor or Chancellor’s Designee
Date
Rev. 7/1/14
Page 15
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