Name: __________________________________________________________________________
Title: ____________________________________________________________________________
Department: ______________________________________________________________________
Approval is requested for permission to engage in the following outside activity:
Company Agency Activity Dates Anticipated Compensation
(Brief Description) (If Applicable)
__________________ __________________ ________ ___________________________
__________________ __________________ ________ ___________________________
__________________ __________________ ________ ___________________________
__________________ __________________ ________ ___________________________
__________________ __________________ ________ ___________________________
__________________ __________________ ________ ___________________________
The University of Texas Health Science Center at Houston equipment may not be used for consulting purposes by any member of the faculty or staff without express approval. In unusual cases where a very unique piece of equipment is not otherwise available, such usage may be authorized, assuming availability of the equipment and adequate compensation to the health science center. In such cases, the faculty or staff member making the request must describe the health science center equipment to be used and justify its request. In no case may the rate of compensation be negotiated by the faculty or staff member. Such negotiations will be between the individual school’s or unit’s financial manager and the entity contracting with the faculty member to consult. Negotiations for use of equipment and rate of compensation will not occur until final approval has been given to the Request for Prior Approval of Participation in Compensated Outside Activities. I acknowledge that I have read and will abide by the applicable Regents’ Rules and Regulations, Series 30103 , as well as UTHSC-H HOOP 2.19, Conflict of Interest.
Signed: _______________________________________ Date: ___________________
APPROVAL RECOMMENDED BY:
______________________________________________ Date: ____________________
Signature
(Direct Supervisor)