KANSAS STATE UNIVERSITY
CONSULTING REQUEST

  Name
Employee ID #
College/Unit
Title
Department
Date form submitted
% Appointment (10ths)
    () nine month
    () twelve month

On April 20, 1995, the Board of Regents adopted a policy on "Commitment of Time, Conflict of Interest, Consulting and Other Employment." Board of Regents policy permits and encourages a reasonable amount of consulting and outside professional work by faculty members and other employees. Conflicts of interest and potential conflicts of interest are inherent in any university setting, and they are not necessarily unacceptable or wrong. Appropriate management of such conflicts ensures the appropriate use of public resources and the integrity of the university and is required by Regents and university policies. More detailed policy statements and guidelines will be published in the University Handbook and the Board of Regents Policy Manual. In order to ensure university compliance with Regents and institutional policy, and with federal and state mandates, the following information must be obtained for review and approval prior to engagement in any external personal, professional activity, except those that occur within a single 24-hour period.  Those activities must be reported on the faculty or unclassified staff members next Annual Declaration and Disclosure.

  • Describe the nature and extent of the proposed activity:
  • How many days per month, on average, will you spend on the activity and over what period of time will you engage in this activity?

     
  • Will any institutional materials, facilities, or services be used? 
  • Yes No
    (If yes, please list of the reimbursement arrangements that have been made.)

     
  • For whom will the activity be performed?
    Type of entity: () Federal agency () Kansas agency () Regents Institution
    () Other (describe)
     
  • Describe fully your relationship with the above-named entity:

     
  • Do you, or does a member of your family (spouse and dependent children), personal household, or associate entities (e.g., corporations, partnerships or trusts), have any managerial role, or equity or other financial interest exceeding 5% or $10,000 (aggregated for you and your spouse and dependent children), in the entity? 
  • Yes No
    (If yes, please describe in the space provided below)
Please read and sign below:
I hereby affirm that the above information is true and complete to the best of my knowledge and that I have read and agree to comply with Regents and University policies on conflict of interest. I further agree to update this report as necessary by submitting another Consulting Request to indicate any significant changes throughout the upcoming academic year.

Signature____________________________________________

Date_________________________________

Please submit to your Department Head for review and approval.

APPROVED:_______________________________________________________________
  Department/Unit Head Date
APPROVED:_______________________________________________________________
  Dean/Appropriate Vice President Date
APPROVED:_______________________________________________________________
  Provost* Date

*For unclassified professionals, other than faculty, the BOR policy on Commitment of Time, Conflict of Interest, Consulting and Other Employment indicates unclassified professionals may consult only on non-university time unless an exception has been granted by the President or his designee. Provost Nellis has been designated by the President to review and approve such requests.