Form Hhs 520 – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND HUMAN SERVICES

REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY

Standards of Ethical Conduct Regulation

HHS Supplemental Ethics Regulation

(5 CFR 2635.803, 5 CFR 5501.106(d))

1. EMPLOYEE’S NAME (Last, First, MI)

8.OFFICE ADDRESS STREET

9. OFFICE CONTACT INFORMATION

AGENCY USE ONLY

1.Nature of Outside Activity

Indicate the type of activity for which you request prior approval, and describe fully the specific duties or services to be performed.

Other

Describe:

If you will provide personal services or products directly to multiple clients, patients, customers, or others, as a self-employed individual or as an independent contractor, alone or jointly with others, check the box below and specify the type of activity or business in which you propose to be engaged, such as legal, medical, accounting, or sales (specify industry or economic sector) and identify any partners or others with whom you provide services or products jointly. Estimate the total number of clients, patients, customers, or persons to whom you would provide services or products during the activity period, rather than listing them in Part II, Item 2.

Self-Employed Activity

For activities involving teaching, speaking, or writing, provide a syllabus, outline, summary, synopsis, draft, or similar description of the content and subject matter involved in the course, speech, or written product (including, if available, a copy of the text of any speech) and the proposed text of any disclaimer that indicates that the views expressed do not necessarily represent the views of the agency or the United States. Check the applicable boxes indicating that these materials are attached. If you are unable to provide this information, or will be delayed in submitting the attachments, please explain below.

2.Outside Employer or Other Entity

Identify the outside employer or other person for whom or organization for which the proposed activity will be performed or conducted. Give the name and title of a contact person. In Items 3 and 4, provide address and contact information for the outside entity.

OUTSIDE ENTITY NAME

3.Outside Entity Address

STREET

5.Location

Indicate the location where the activity or services will be performed.

6.Travel

Indicate whether travel is involved, and if so, whether the transportation, lodging, meals, or per diem will be at your own expense or provided by the outside entity in kind or through reimbursement. Describe arrangements and provide estimated costs of items to be furnished or reimbursed by the outside entity.

Yes

No

Describe:

7.Time

Provide details with respect to the duration, frequency, and timing of the activity. If your request for prior approval is granted, the approval is effective for a period not to exceed one year from the date of approval. If you wish to continue an activity beyond the one year approval period, you must renew your request no later than thirty days prior to the expiration of the period authorized.

c. Will work BE performed entirely outside of usual working hours?

8.Compensation

Indicate whether the activity is compensated, and if so, answer the questions below.

Yes No

a. Method or Basis of Compensation (Check all boxes that apply)

Indicate the total amount of compensation to be received for the proposed activity for the period covered by this request. Do not include the amount of any travel expenses to be provided by the outside entity that were reported in Part II, Item 6.

$

c.Payor

If any compensation will be received from a payor other than the entity to which personal services will be provided, identify the payor and explain.

d. Funding Source

Indicate whether any compensation is derived from an HHS grant, contract, cooperative agreement, or other source of HHS funding or if the services to be performed are related to an activity funded by HHS, regardless of the specific source of the compensation.

e. Grantee, Contractor, or Other Status

For activities involving the provision of consultative or professional services, indicate whether the client, employer, or other person on whose behalf the services are performed is receiving, or intends to seek, an HHS grant, contract, cooperative agreement, or other funding relationship.

f.Record of Prior Compensation from Same Source

Identify the source, activity, amount and date of any compensation received, or due for services performed, within the last six calendar years and the current year through the date this request is submitted, from the person for whom or the organization with which the current work or activity will be done (including any amount received or due from an agent, affiliate, parent, subsidiary, or predecessor of the proposed payor). This information must be provided as to any outside activity performed for the person or organization that is the subject of this request for approval. Include any prior activity that is the same or similar to the present request, as well as any unrelated activity involving the same source.

CURRENT

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ADDITIONAL SPACE