Florida Atlantic University

Report of Outside Employment or Professional Activity for FAU Employees


Select:

This report of proposed outside employment/professional activity is completed to comply with the policies and regulations of the University. Please note that this report must be submitted and necessary approvals obtained on an annual basis for any activity continuing beyond June 30 of the year referenced. A separate report must be filed for each outside employment or outside activity. If several activities are engaged in with a single outside employer, these can be included in a single outside employment/activity report.

If the outside employment/activity involves an entity or agency doing business with or proposing to do business with the University at the time this form is completed, the employee should also attach a REPORT OF SPECIFIED INTEREST form.

EMPLOYEE INFORMATION
Employee Name
Title
Department/Unit
Employee Status: (please select one)
PROPOSED OUTSIDE EMPLOYMENT ACTIVITY

Name of Employer/Business Entity/Client



Location (City, State, Country)


Anticipated Date(s) of Outside Employment

Avg # Hours per Week you will engage in this Outside Activity
Nature of Employment/Activity: (please check all that apply)
1. Description of Employment Activity (attach a page explaining the outside activity in detail including: a. Business structure (a corporation, partnership, LLC, individual, etc.); b. Name of business; c. List of clients; d. Nature of service or product supplied; e. Whether the activity is one that you could do as part of your FAU employment.)
2. Are FAU employees and/or students involved in the outside activity?
   (If yes, please list those students or employees.)
3. Are you a faculty advisor or supervisor to any person listed in item 2 above?
   (If yes, please list those students or employees and your position in relation to them.)
4. Total number of outside activity and financial interest reports submitted during this contractual period including this report.
5. Estimate of total number hours spent per week during this contractual period on all outside activities including this one.
6. Will University equipment, facilities, or services be used in the course of this activity?
   (If yes, please attach a University Equipment, Facilities, and Services form with this request.)
7. Do you, your spouse, domestic partner, dependent or child have an interest in and/or an employment or contractual relationship with a business entity, including your own, that is or might be doing business with FAU or any of FAU’s direct support organizations?
   (If yes, please list the outside entity and the division/department within FAU or the name of the FAU direct support organization included.)
8a. Are you required as a condition of outside employment or activity to waive any rights you may have to intellectual property you develop, including patent rights?
   (If yes, the Division of Research must review and approve the employment/activity.)
8b. Will you be working for an entity that has either licensed, optioned, or acquired intellectual property from the University? This includes your own company that has licensed intellectual property from the University.
   (If yes, the Division of Research must review and approve the employment/activity.)
9a. Are you engaged in sponsored research at FAU (i.e., research funded by a non-FAU entity)?
   (If yes, the Division of Research must review and approve the employment/activity.)
9b. If yes, does your outside business activity cause you to have a "significant financial interest" under the DOR FCOI Policy?
   (If yes, the Division of Research must review and approve the employment/activity. In addition, you will need to complete or update the Disclosure of Significant Financial form for each funded project that is affected by this outside activity.)
Instructional faculty, please complete
Will classes be missed?
How will classes be covered?
All employees, please complete
Has leave request been submitted?
Has leave request been approved?
If you answered "Yes" to questions 8 or 9 above, please send this form to the Director of Sponsored Programs within the Division of Research. If not, send this form to the Provost's Office.


I hereby certify that the outside employment or professional activity reported here does not consitute a conflict of interest under Chapter 112, Florida Statutes, and will not intefere with my assigned duties and responsibilities at Florida Atlantic University. I agree to notify the University immediately if the nature of the activity described in this report changes.
Employee Signature:

For chair/supervisor and dean/director, by approving below you certify that you have reviewed the above information with the applicant:
REVIEWER REVIEWER'S SIGNATURE DATE APPROVAL
Chairperson or Supervisor
Dean or Director
Division of Research (if applicable)
Provost or VP

Click on the button to create a PDF file and forward as follows: 1) Send to chairperson of your department or supervisor to review and sign; 2) Send to your dean or director to review and sign; 3) Send to Sponsored Programs in the Division of Research to review and sign or to the Provost office as indicated above.