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OUTSIDE EMPLOYMENT OR BUSINESS ACTIVITY REQUEST

Kentucky State University

Section 1 - To be completed by employee

Employee Name (Last, first, middle) 2. Position Title

Date of Hire 4. Supervisor Name 5. KSU Work Schedule: ☐F/T ☐P/T ☐Intermittent ☐Temp ☐ Seasonal ☐Other

Are you now engaged in any outside employment? ☐Yes ☐No (If yes, explain. Attach additional sheet if necessary)

Prospective Employer's Name and Address 8. Type of Business 9. Proposed Work Schedule (Days/Hours)

Proposed Start and Ending Date:

Describe the Outside Employment or Business Activity (Use Additional Sheets if Necessary)

I hereby certify that the statements made in this Section are complete and correct to the best of my knowledge.

Employee Signature Date

Section 2 - Recommendations of Supervisory Officials

Receipt of Initial Request: B. Receipt of a fully Completed Request: C. Deadline for Approval/Disapproval Date:

Date: Date:

In considering this request for outside employment or business activity, I have reviewed the Kentucky State University Employee and/or Faculty Handbooks, Conflict of Interest Policy and the Code of Conduct/Ethics policies and understand the employees' responsibilities and obligations to the University. My recommendation is made in accordance with those provisions.

Immediate Supervisor: ☐ Approval ☐ Disapproval

(Signature and Title) (Date)

Vice President: ☐ Approval ☐ Disapproval

(Signature and Title) (Date)

General Counsel: ☐ Approval ☐ Disapproval

Copies: Official Employee File, Employee, Supervisor

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(Signature and Title)

(Signature and Title) (Date)

(Date)

Section 3 – Approval or Disapproval

Denials of outside employment or business activity must include a statement of the reasons for disapproval. Review the factors contained in section 2(D) above and attach a complete statement setting forth the rationale for disapproval.

Director of Human Resources: ☐ Approval ☐ Disapproval

(Signature and Title) (Date)

GENERAL

This statement is provided pursuant to Privacy Act of 1974, 5 U.S.C. § 552a, for individuals requesting authorization for outside employment and business activities.

PURPOSES AND USES

The information you furnish on this form will be used by your supervisory officials to evaluate your request. The information will be used on a “need to know” basis by University officials and when appropriate, may be furnished to other individuals and entities as described in the routine uses for the General Employment and Payroll system of records.

EFFECTS OF NONDISCLOSURE

Providing the requested information is voluntary, however, failure to furnish the information required may result in the disapproval of your request.

INSTRUCTIONS FOR COMPLETION

Section 1 - Completed by Employee Each item in this section must be completed accurately; failure to do so may result in delay of disapproval of the request. If information regarding any item(s) is: not applicable, not known, or does not apply to this subject request, the appropriate entry must be made and accompanied by an explanation.

Section 2 - Completed by Immediate Supervisor, Vice President and the Director of Human Resources. Management should make a final decision on this request to engage in outside employment or business activity as soon as possible in accordance with University policy, but not later than ten (10) workdays from receipt of the fully completed request. Upon initial receipt of a request, the immediate supervisor must complete item 2A. At the same time, the request should be reviewed for completeness with particular attention given to Section 1, Item 13, which should describe in detail the requested activity. If additional information is necessary the request should be returned to the employee and the employee advised in writing, if necessary, of the additional information required. Upon receipt of a fully completed request, Item 2B, should be completed and the deadline for approval/disapproval, Item 2C, computed (in workdays) and noted. Any reasons for a delay of the process should be documented. The immediate supervisor and all subsequent reviewers should carefully consider item 2D, complete the appropriate blocks, provide his or her recommendation and attach any remarks, comments or concerns.

Copies: Official Employee File, Employee, Supervisor

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Section 3 - Completed by the Director of Human Resources

Management must make a final decision on this request to engage in outside employment or business activity as soon as possible, but not later than ten (10) workdays from receipt of the fully completed request.

Following receipt of a fully completed request careful review of all information contained on the request should take place. A complete statement setting forth the rationale for any disapproval must accompany the request when returned to the requesting employee.

Copies: Official Employee File, Employee, Supervisor