Form Per De 1 – Fill Out and Use This PDF

The Per De 1 form is a crucial document issued by the Connecticut Department of Administrative Services for the purpose of managing dual employment within state agencies. It outlines a procedure for employees who hold or are considering a second position within the state's jurisdiction, ensuring that such arrangements do not result in conflicts of interest or duplicate compensation. Comprehensive guidelines are provided for both the primary and secondary employing agencies to verify and document the employee's work schedule, duties, and employment period, facilitating a transparent and accountable approach to dual employment. For detailed guidance on how to fill out the Per De 1 form, click the button below.

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Form Per De 1 PDF Details

In Connecticut, managing dual employment within state agencies requires careful coordination to ensure compliance with regulations and the prevention of conflicts of interest. The PER-DE-1 form, provided by the Department of Administrative Services since its revision in January 2005, facilitates this process. This form is used when an employee of a state agency takes on an additional role within another state entity. It lays out the framework for documenting the employee’s schedule, the nature of the secondary position, and the responsibilities tied to it. Moreover, it ensures that the work performed in the secondary position does not overlap with the duties of the primary employment, guarding against potential conflicts of interest and double compensation for the same hours worked. By requiring certifications from both the primary and secondary employing agencies, the form encourages transparency and accountability. It also mandates that an updated dual employment form be filed for each new period of employment, thereby maintaining up-to-date records of the employee’s engagements. The precise scheduling details and the requirement for potential conflict of interest evaluations further underscore the form’s role in maintaining the integrity of the dual employment approval process.

Question	Answer
Form Name	Form Per De 1
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	psaDualEmpForm dual employment form mta

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State of Connecticut Human Resources

Dual Employment Request Form

Form #: PER-DE-1

Revision Date: 01/2005

_____________________________________________________________________________________________

Instructions for SECONDARY AGENCY: Complete this form when an employee provides services under an authorized PER-

301 for a second position. Keep a copy of the form in a suspense file and forward the original to the primary agency. When certification from both the primary and secondary agency is complete, process the employee according to the guidelines in General Letter 204.

Employee		Today's Date

Employee Address	Present Position Title	FLSA
		❏ Exempt ❏ Non-Exempt

Primary Agency

SECONDARY AGENCY - Agency where employee is being considered for a second job

Facility of Secondary Employment	Title of position sought

Duties to be performed:

Dates duties will be performed: (A new dual employment form must be completed and placed in the employees' personnel file for each new period of employment.)

Start Date:				End Date:
The work schedule will be as follows:
Day	Friday	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday
Time In:
Time Out:

SECONDARY AGENCY CERTIFICATION

SIGNED (Agency head or authorized designee)	TITLE	DATE

Instructions for PRIMARY AGENCY –Complete and return to secondary agency for documentation. Retain a copy for your files.

Position Title:					POTENTIAL CONFLICT OF INTEREST?
						YES	NO
Duties Performed:

Current Work Schedule
Day	Friday	Saturday	Sunday	Monday		Tuesday	Wednesday	Thursday
Time In:
Time Out:

Primary Agency Certification

I certify that the duties are being performed outside the responsibility of the agency of principal employment, the hours worked at this agency are documented and reviewed to preclude duplicate payment, and that no conflicts of interest exist between services performed. If for any reason there should be a change in the hours and/or days of work as originally indicated, an amended request with the required justification will be submitted.

RECOMMEND	SIGNED (Agency head or authorized designee)	TITLE	DATE
YES NO

This form provided by the Department of Administrative Services

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1. To start with, once filling out the Form Per De 1, begin with the section with the next blank fields:

2. The next part is usually to fill in the next few blanks: Employee Employee Address Primary, POTENTIAL CONFLICT OF INTEREST, YES NO, Saturday, Duties Performed Current Work, SIGNED Agency head or authorized, Wednesday, Thursday, Tuesday, Monday, Sunday, TITLE, DATE, and This form provided by the.

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