UNIVERSITY OF NEBRASKA

APPLICATION FOR AUTHORIZATION TO ENGAGE IN OUTSIDE PROFESSIONAL ACTIVITY

Date_____________________________ Department______________________________

Name_______________________________ Title _________________________________

Date(s) of Activity__________________________________________________________

Nature of Activity (please describe the general nature of the outside activity proposed, i.e., consulting, research, teaching, etc.) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In order to engage in outside professional activity, the Board of Regents requires that you answer the following questions.  These are to protect you and the University.   They will permit you to obtain the proper approvals so you will not be in violation of your obligations to the University.  They will also provide a check list to assure that you and the University are in compliance with those regulations that govern the University, particularly if your activity could be categorized as research.    

PART I: CONDITIONS REQUIRING BOARD OF REGENTS APPROVAL

1.		Will you be retained to provide professional services outside the University to an individual person, client, company, firm or governmental agency over a time period lasting more than two years?		Yes______		No_______

If your answer is “yes” you will require approval of the Board of Regents before engaging in this activity.

2.		Will this outside professional activity, combined with all other professional activity which has been approved, prevent you from performing your regular duties at the University by totaling more than an average of two days per month?  
	Yes ___________    No___________________

If your answer is “yes” you will require approval of the Board of Regents before engaging in this activity unless, with the approval of your Dean, you either (1) reduce your FTE (and accordingly your University salary and fringe benefits) to reflect the time reduction in your regular duties or you arrange to have the company or institution reimburse the University directly for the salary and fringe associated with the time reduction in your regular duties.

	In lieu of seeking Board of Regents approval I intend to ____reduce my FTE by ___% or _____ arrange for reimbursement to the University for _____% of my salary and fringe benefits.

PART II:   CONDITIONS REQUIRING DEANS APPROVAL

1.		Is your outside activity going to be performed off the premises of the University and without the use of University equipment or materials?   Incidental use of the office space, phone, or desktop computers supplied to you by the University as part of your normal functions as a faculty member is not regarded as the use of University premises or equipment.   University premises do not include land or buildings leased by the University to private companies exclusively for their use, such as in a technology park.  Yes ____________   No _______________.

If your answer is “Yes”, you do not need to complete the remainder of this form but you must obtain the approval of your Dean before engaging in the outside activity.   If your answer is “No” you must complete the rest of the form.

2.		To what extent will the University be reimbursed for any costs borne by the University associated with your use of University premises, equipment, or materials?   ________________________________________________________________________________________________________________________________________________________________________________________________________________________

3.		If you perform work for an outside contractor while on the University’s premises or through the use of University equipment and materials, you remain subject to the same regulations that would apply were you doing similar work as part of your University responsibilities.   Particularly, if your work were characterized as “research”, the full range of federal research compliance mechanisms is applicable.  Please review the following list of potential issues and inform your Dean if any might be applicable.

A.		The activity is likely to result in a discovery, writing or software that is subject to the Board of Regents policy on intellectual property.
B.		The activity involves experimentation with or on human subjects or involves surveys of human subjects.
C.		The activity involves the use of animals.
D.		The activity may involve students, faculty, or third persons who are foreign nationals.   (Federal regulations relating to national security prohibit foreign nationals from certain countries to have access to various technologies including computer technology.)
E.		The activity involves the use of hazardous chemicals, radioisotopes, biological agents, or recombinant DNA.
F.		I am currently working on a separate federally funded research project that requires “effort reporting” through Personal Activity Reporting system.
G.		The activity involves my use on behalf of another of intellectual property owned by me, by the university, or by a third person other than the party for whom I propose to provide services.
H.		The activity involves the use of information classified by the government as secret, top secret, or any other classification that would obligate you or the University to keep it in confidence.
I.		The activity requires that I sign a confidentiality agreement that would prevent me from publishing information about the activity.

	I have read the above listed items A through I.    

	_____   None are applicable to my proposed outside activity.

	_____    One or more may be applicable.  (Please circle applicable issues).

If you have difficulty or do not understand any of the items listed above, please consult your Dean or office responsible for federal regulatory compliance.  If one or more of these items may be applicable to your proposed activity, your Dean is required to consult with the regulatory compliance officer of your campus before granting approval for you to proceed.

Approval Requested:_______________________________(Applicant)   Date: ______________

Approval Recommended: ___________________________(Head of Department) Date: _________

Approval Recommended (Granted):____________________(Dean) 	Date: ___________

Approval by the Board of Regents Required:     Yes_____   No _______

	For the Chancellor______________________________ Date: __________________

	For the Board of Regents _________________________Date:___________________