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

1

2

3

4

5

6

ADDITIONAL SPACE

1.Nature of Official Duties

Describe the principal duties and responsibilities of your current position. You may attach a copy of your position description in lieu of providing the description unless you currently have significant duties or assignments that are not reflected in that document.

Position Description Attached

2.Relationship of Official Duties to Outside Activity

Describe any official duties that relate in any way to the proposed activity. If none, explain why.

3.Effect of Official Duties on Outside Employer

In performing your official duties, explain how your actions or the matters upon which you may be called upon to work could affect the interests of the person for whom or the organization for which the proposed activity will be performed. If the exercise of your official duties would not have such an effect, explain why.

4.Assignments Involving Outside Employer

Describe any official duty assignments or other interactions you have had that involve the person for whom or the organization for which the proposed activity will be performed and indicate when such assignments or interactions occurred. If none, explain.

The undersigned employee certifies that the notices in Part VIII have been read and understood and that the statements made and information provided on this form are true, complete, and correct to the best of the individual’s knowledge.

1.Summary of Applicable Law

An employee cannot undertake an outside activity that conflicts with the employee’s official duties. An activity conflicts with official duties: (a) if it is prohibited by statute or regulation; or (b) if, under the standards in 5 CFR 2635.402 and 2635.502, it would require the employee’s recusal from matters so central or critical to the performance of his or her official duties that the employee’s ability to perform the duties of his or her position would be materially impaired. Such a recusal would likely arise where the outside activity involves a person or entity that is regulated by, does business with, receives grants or other benefits from, or is otherwise substantially impacted by the programs, policies, and operations of the employee’s agency, and the employee normally would be involved personally and substantially in such matters on a frequent basis or as a principal duty. In addition, an activity may be improper if the circumstances suggest that the employee received an outside business opportunity based on his or her official position or would create the appearance of using public office for the private gain of an outside entity. An employee also must endeavor to avoid any actions that create the appearance of a violation of law or the ethical standards. Special rules apply to activities involving fundraising, expert witness testimony, teaching, speaking, writing, or editing, and activities with foreign entities. Certain categories of employees, such as those in FDA, NIH, and OGC, are subject to component specific rules on outside activities. Refer to the Standards of Ethical Conduct, 5 CFR part 2635, subpart H, and the HHS Supplemental Ethics Regulation, 5 CFR part 5501.

2.Supervisor’s Statement

Describe the extent to which the employee’s official duties are related to the proposed outside activity.

3.Recommendation

The undersigned supervisor, identified in Part I, Item 10, has reviewed the employee’s responses, obtained additional information where appropriate, and recommends the following action:

Recommend Approval

If this box is checked, the supervisor understands that if the outside activity is approved, the employee may be disqualified from performing official duties that involve or affect any outside entity with which the employee has an outside employment, consulting, or similar relationship. If the activity constitutes employment or service as an officer, director, or trustee, or in another fiduciary role, the recusal obligation may extend not only to government matters that specifically involve or affect the outside entity, but to those matters that affect generally the industry or economic sector in which the outside entity operates. The supervisor concludes that any work assignments involving specific or general matters from which the employee will be recused can be reassigned to another individual and are not so central or critical to the performance of the employee’s official duties that the employee’s ability to perform the duties of his OR her position would be materially impaired.

Recommend Disapproval

If this box is checked, explain the reason(s) in the additional space provided on the last page of this form.

4.Organization

5.Committee

If the reviewer acts on behalf of a committee, identify the body and record any dissenting views in the "Comments" below.

6.Review

Review the employee’s answers and indicate whether you concur in the supervisor’s recommendation. Explain your reason(s) in the space below. Sign and date the form in the space provided.

7. Comments

( )

4.Organization

5.Ethics Review

Review the employee’s answers and the supervisor’s recommendation. Consider the assessment of any management official, committee, or other intermediate reviewer. Based on the information provided and applying the standard for approval prescribed in 5 CFR 5501.106(d)(5), indicate whether the activity can be approved or permission must be denied. Explain your reason(s) in the space below and describe any actions deemed necessary to ensure compliance with applicable ethics laws. Sign and date the form in the space provided.

Request as described may be approved

Request may be approved subject to conditions noted in Comments Section

Request as described must be denied

Other disposition noted in Comments Section

6. Comments

( )

4.Organization

5.Decision

Based on the foregoing statements and any supporting documentation, the recommendations of the supervisor and, if applicable, any management official, committee, or other intermediate reviewer, and the review by the agency ethics official, the disposition indicated below constitutes my written determination, pursuant to 5 CFR 2635.803 and 5 CFR 5501.106(d), that the request to engage in the identified outside activity is:

Approved

Approved subject to conditions

Denied

6. Specified Conditions (if any)

7. Comments

APPROVAL OF AN OUTSIDE ACTIVITY DOES NOT RELEASE YOU FROM A CONTINUING LEGAL OBLIGATION TO DISQUALIFY YOURSELF FROM OFFICIAL ASSIGNMENTS AFFECTING YOUR OUTSIDE EMPLOYER OR THE ENTITY TO WHICH YOU ARE PROVIDING PERSONAL SERVICES. WHILE PERFORMING AN APPROVED OUTSIDE ACTIVITY, ANY ACTIONS TAKEN IN CONFLICT WITH APPLICABLE ETHICS LAWS MAY SUBJECT YOU TO CRIMINAL PROSECUTION OR DISCIPLINARY PROCEEDINGS.

EXCERPTS FROM THE STANDARDS OF ETHICAL CONDUCT FOR EMPLOYEES OF THE EXECUTIVE BRANCH AND THE DEPARTMENT OF HEALTH AND HUMAN SERVICES SUPPLEMENTAL AGENCY ETHICS REGULATIONS:

TITLE 5 CODE OF FEDERAL REGULATIONS

PRIVACY ACT STATEMENT

The Ethics in Government Act, 5 U.S.C. App. § 101, et seq., Executive Order 12674, as amended by Executive Order 12731, Sections 301 and 7301 of Title 5 of the U.S. Code, and Sections 2635.803 and 5501.106(d) of Title 5 of the Code of Federal Regulations authorize the collection of this information. Disclosure of this information is mandatory for employees seeking prior authorization from an agency designee to pursue outside employment or activities pursuant to Sections 2635.803 and 5501.106(d) of Title 5 of the Code of Federal Regulations. Failure to provide all or part of the requested information may result in denial of the request for approval of the outside employment or activity. Falsification of information or failure to file or report information required to be reported may subject the employee to disciplinary action. Knowing and willful falsification of information required to be reported may subject the employee to criminal prosecution. The primary use of this information is to allow HHS supervisors, management officials, and agency ethics officials to make necessary determinations concerning employee requests for prior approval of outside employment or activities in order to prevent a conflict of interest or other violations of the statutes, regulations, and executive orders governing employee conduct. The information is also requested, pursuant to 5 C.F.R. §§ 2638.203(b)(9),(10), and (11), for the purpose of evaluating ethics program administration, as well as the Department’s supplemental ethics regulations, to determine their continued adequacy and effectiveness in relation to current agency responsibilities and to ensure that prompt and effective action is taken to remedy violations or potential violations, or appearances thereof, of conflict of interest and related ethics provisions. Additionally, this information may be disclosed to: (1) the Office of Personnel Management, Office of Government Ethics, Merit Systems Protection Board, Office of the Special Counsel, Equal Employment Opportunity Commission, Federal Labor Relations Authority, Federal Service Impasses Panel, Federal Mediation and Conciliation Service, and an arbitrator, in carrying out their functions; (2) a Federal, State, or local agency charged with investigating or prosecuting violations of, or implementing, the law, in the event there is an indication of a violation or potential violation of civil, criminal or regulatory law; (3) a Federal, State, or local agency maintaining enforcement records or other pertinent records, such as current licenses, if necessary to obtain a record relevant to an agency decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other benefit; (4) the National Archives and Records Administration or the General Services Administration in records management inspections; (5) the Office of Management and Budget during legislative coordination on privacy relief legislation; (6) Federal agencies with power to subpoena other Federal agencies’ records; (7) a court or party in a court or Federal administrative proceeding if the Government is a party or in order to comply with a judge-issued subpoena; (8) private firms with which the Department may contract for the purpose of collating, analyzing, aggregating or otherwise refining records; (9) a Member of Congress or a Congressional office, pursuant to an inquiry made at the request of the individual who is a subject of the record; (10) the Department of Justice in defense of litigation; and (11) contractors and other non-Government employees working for the Federal Government to accomplish a function related to an Office of Government Ethics Government-wide system of records. This confidential report will not be disclosed to any requesting person unless authorized by law. See the OGE/GOVT-2 Government-wide executive branch system of records.

STAPLE ATTACHMENTS TO THIS PAGE

List each attachment in the space provided and append copies.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

ADDITIONAL SPACE

Identify the part and item number to which the additional information refers.

ADDITIONAL SPACE (continued)

Identify the part and item number to which the additional information refers.

Department of Health and Human Services Office of the Secretary

Office of the General CounSel Ethics Division Washington, DC 20201 (202) 690-7258