Policy #54
Appendix D

NOTICE OF INTENT TO ENGAGE IN EXTERNAL PROFESSIONAL ACTIVITIES FOR PAY

Date:__________________________

_________________________________________ (name) intends to engage in external professional activity for pay under the following conditions:

1. Name and address of contracting organization:_________________________________

2. Nature of proposed activity:_______________________________________________

3. Beginning date and anticipated duration of activity: ______________________________

4. On average, how many hours per week will be devoted to this activity?

a. For 12-month employees, for the anticipated duration of the activity, within the current fiscal year ending June 30: __________________________________________

b. For 9-month employees, for each component part of the academic year, as applicable, within the current fiscal year ending June 30 (see above paragraph 2):

(1) Second summer session (post July 1) _______________________________

(2) Fall semester __________________________________________________

(3) Spring semester ________________________________________________

(4) First summer session (pre July 1) __________________________________

5. Total number of hours to be devoted to activity: ________________________________

6. Identify any classes, meetings or other University duties that will be missed because of involvement in the proposed activity (respond separately for each applicable component part of the academic calendar if 9-month employee) and state what arrangements have been made to cover any such duties:

Duties Missed Arrangements to Cover _________________________________________

_______________________________________________________________________

_______________________________________________________________________

7. Use of University resources in connection with proposed activity:

a. Will the activity entail the use of any University resources? ( ) Yes ( ) No

b. If yes, describe what resources will be used. ______________________________________________________________________

______________________________________________________________________

8. To your knowledge, does the contracting organization above provide funding which directly supports any of your University duties or activities? ( ) Yes ( ) No

9. To be completed if the contracting organization is a private firm:

a. Do you or any member of your immediate family own an equity interest in the contracting organization? ( ) Yes ( ) No

b. Do you hold an office in the contracting organization? ( ) Yes ( ) No

10. Performance of the above described activity is consistent with university and UNC Board of Governors policy on conflicts of interest and commitment and external professional activities (300.2.2).

_________________________________________________
Signature

_________________________________________________
Department

_________________________________________________
Academic Rank or Job Title

_________________________________________________
Administrative Title (if any)

_________________________________________________
Signature Department Head (or supervisor)

ADMINISTRATIVE ACTION ON NOTICE OF INTENT

1. Reviewed; activity determined to be consistent with university policy .

_______________ ____________________________________________
Date Department Head

Other action (as required): ________________________________________

_______________ _____________________________________________
Date Dean or Other Administrative Officer*

* Approval by Dean or other administrative officer to whom Department Head reports is required if question 8 or question 9a or 9b is answered in the affirmative.

2. Reviewed; activity determined not to be consistent with university policy .

_______________ ______________________________________________
Date .......................Department Head

Action on appeal (if any):
________________ ____________________________________________
Date .........................Action taken

____________________________________________
Dean or Other Administrative Officer

________________ ____________________________________________
Date .........................Action taken

____________________________________________
Chancellor

Any administrative action approving a "Notice of Intent" shall be effective only for the remaining balance of the fiscal year (in the case of 12-month employees) or for the balance of the academic year (for 9-month employees); see above paragraph 2.