McNeese State University Outside Employment/Income, Conflict of Interest, and Conflict of Commitment Disclosure Form

All McNeese employees must complete this form on an annual basis.

This form is designed to be filled out electronically and then printed, signed, and submitted to your immediate supervisor.

Employees should review the policy on Conflict of Interest and Conflict of Commitment.

All employees must complete the disclosure form each year and must update this form if there are any significant changes in outside interests or commitments, or your McNeese position/responsibilities during the year. All employees have a responsibility to report on an annual and ad hoc basis when professional activities, financial interests and relationships could have, or could be perceived to have, an impact on his/her University responsibilities. This form requires the individual to report any and all leadership roles, secondary commitments and financial interests outside of McNeese. In addition, this form requires the individual to report any and all leadership roles, secondary commitments and financial interests that the individual’s immediate family may have that could reasonably be expected to affect, or appear to affect, the professional judgment of a McNeese employee. Faculty and Staff must submit completed disclosure forms to their immediate supervisor. Newly hired or affiliated employees must submit a Disclosure Form within the first three months of employment or affiliation, and must thereafter comply with the annual filing deadline each fall. Failure to submit a completed Disclosure Form may have significant employment consequences. Immediate supervisors must review and sign every disclosure form received from each employee before submitting to the Dean/Administrative Supervisor responsible for their unit. Deans/Administrative Supervisors will review disclosures and complete Part 4, the Disclosure Review, according to instructions before submitting to the Vice President/President responsible for their unit. Vice Presidents/President will review disclosures and management plans, and submit forms with recommended action to the COI Committee. COI Committee will accept or recommend revisions for acceptance of management plans. All disclosure forms will be maintained in the office of the President.

All italicized words are defined in the Conflict of Interest and Conflict of Commitment Policy and link to their definition.

Disclosure Details : :
Disclosure Statement Status  
Personal Details





Classification      

Part 1: Conflict of Interest

Answer the following 12 questions based on the past year or expected during this current year. (For each question answered as "Yes," please provide full details of referenced activity, including, as appropriate, the type of activity, the outside entity, relationship with outside entity, level of involvement, etc.)

  1. Do you or a member of your immediate family own an interest in excess of 25% in any business that has conducted or might conduct business with McNeese?  


    (Maximum characters: 675)
    You have characters left.
  2. Do you or your immediate family members or entity in which you or your immediate family hold an interest, work for or have a financial, employment, consulting or other business relationship,
    of which you are aware, with any individual, company or organization that:
    1. Sought to or currently provides goods or services to the University?  
    2. Gave donations of gifts or money to the University, including sponsoring your University teaching or research activities?  
    3. Received or will receive a license through the University to intellectual property that you invented, co-invented, or was from your lab?  
    4. Received services or products from the University?  


    (Maximum characters: 675)
    You have characters left.
  3. Do you, your spouse, or any of your dependents have or expect to have a significant financial interest in, serve on the board of directors of, hold an officer position on, or have any employment
    or consulting relationship with, any business, organization or public or private agency from which you have received or expect to receive support for research or a sponsored project?      

    If yes, in an attached statement, provide for each: a) The name and business address of the entity, b) Your position or role in the organization; and c) A brief description of the nature and/or responsibilities of each position listed.

  4. a) Have you or any member of your family or any entity in which you or your immediate family hold an interest received a single gift or multiple gifts from a current or prospective University
    vendor, service provider, individual, student, parent or guardian or any third party who has a financial interest in or is seeking some benefit from the University? (Gifts include, but are not
    limited to, complimentary reduced fee, gift baskets, food, meals, refreshments, entertainment, equipment, travel, and tickets to sporting and other events. Examination copies of textbooks and
    similar materials given to faculty are not considered gifts).       (If yes, please explain in an attached statement.)
    b) If you answered "Yes" to the question above, did you submit to and receive authorization from the University's President or Ethics Designee that the 'gift' was within the guidelines of exceptions
    as stated in the Louisiana Code of Governmental Ethics Revised Statues and/or Federal Regulations? (Section 130 of the Faculty/Staff Handbook)      
  5. Have you disclosed confidential University information to unauthorized third parties?   (If yes, please explain in an attached statement.)
  6. Have you used University resources, including, but not limited to, funds, property, materials, equipment, facilities, university personnel or students for a personal or non-University related
    activity (including in your consulting or pro bono activities)? (La. Const. Article 7: Section 14)       (If yes, please explain in an attached statement.)
  7. Have you arranged for or permitted third parties access to or use of University resources, including, but not limited to, funds, property, personnel/staff or students for non-University
    related purposes?       (If yes, please explain in an attached statement.)
  8. Have you or anyone in your immediate family obtained a Financial Interest in any contract, subcontract, or agreement with respect to a Community Development Block Grant (CDBG) assisted
    activity or with respect to the proceeds from a CDBG assisted activity for yourself or those with whom you have business or immediate family ties?       (If yes, please explain in an attached statement.)

    Note: If you answered "yes" to the question listed above, please note that you will not be allowed to exercise any functions or responsibilities with respect to CDBG-assisted activities during your tenure or for a period of one (1) year thereafter (24 CFR § 570.611).

  9. Have you been directly involved in the hiring of a member of your immediate family, or do you directly or indirectly review, determine compensation, or assign work to a member of your
    family working at McNeese? (R.S. 42:1119-Nepotism)       (If yes, please explain in an attached statement.)
  10. During the past year, have you been convicted of a felony; or a misdemeanor involving money; or been debarred, suspended or excluded by a duly authorized regulatory agency?   (If yes, please explain in an attached statement.)
  11. Are there any other relationships, consulting arrangements, financial relationships, commitments or activities you or any member of your immediate family had in the last 12 months or currently
    have that might present or appear to present a conflict of interest or conflict of commitment with your McNeese State University employment? Such relationships include, but are not limited to,
    financial or fiduciary interests or activities.       (If yes, please explain in an attached statement.)

Part 2: Conflict of Commitment

In accordance with Louisiana Revised Statutes and Policies of the University of Louisiana System Board of Supervisors, each full-time employee of McNeese State University must report any outside employment for which a salary, retainer, fee, or other form of remuneration is paid. (See ULS PPM FS-III.VII.-I)

ULS PPM FS-III.VII.-1 defines outside employment as any non-University/College activity for which economic benefit is received, including but not limited to:

  1. Employment with any non-University employer. (Including Pro-rodeo; athletic Camps owned by Head coaches; Book royalties)

  2. Contracts to provide consulting, personal, or professional services to non-University individuals or entities, including publishing agreements or arrangements.

  3. Self-employment or operation of a business. (Including Athletic and Other camps)

Outside employment shall be performed only outside of assigned working hours or responsibilities, or during a period of paid or unpaid leave.

Answer the following questions based on the past year or expected during this current year.

  1. Did you or do you currently engage in any outside employment and consulting activities?   (If yes, please complete Part 3: Outside Employment/Income Activity and list each outside employment/income activity separately.
  2. If you engage in outside employment or consulting activities, did you report to the head of your department or to your immediate supervisor in writing the nature and extent of such activities,
    and the amount of time the work will require and request appropriate university approvals (ULS PPM FS III.VII.1)?      
  3. Do you teach courses for credit outside McNeese State University?   (If yes, you must submit a copy of the employment contract with this form, and obtain prior written approval from the University President.)
  4. Have you used McNeese's name or resources in connection with outside employment/income?  

Part 3: Outside Employment/Income Activity

Each outside employment/income activity must be disclosed separately. Should an outside employment activity be initiated subsequent to the annual disclosure date, a separate form must be submitted at that time.

Outside Employment/Income Activity 1



  5. Does this outside employment, combined with any other outside employment previously approved, prevent or infringe upon the performance of regularly assigned full-time duties (including
    classes, course preparation, advising, office hours, or other University related work)?      


    (Maximum characters: 675)
    You have characters left.
  6. Does this outside employment involve any other governmental entity (local, state, and federal)?  


    (Maximum characters: 675)
    You have characters left.

Outside Employment/Income Activity 2



  5. Does this outside employment, combined with any other outside employment previously approved, prevent or infringe upon the performance of regularly assigned full-time duties (including
    classes, course preparation, advising, office hours, or other University related work)?      


    (Maximum characters: 675)
    You have characters left.
  6. Does this outside employment involve any other governmental entity (local, state, and federal)?  


    (Maximum characters: 675)
    You have characters left.

Outside Employment/Income Activity 3



  5. Does this outside employment, combined with any other outside employment previously approved, prevent or infringe upon the performance of regularly assigned full-time duties (including
    classes, course preparation, advising, office hours, or other University related work)?      


    (Maximum characters: 675)
    You have characters left.
  6. Does this outside employment involve any other governmental entity (local, state, and federal)?  


    (Maximum characters: 675)
    You have characters left.

(Report additional outside employment/income activity on a separate page if needed.)

 

Certification

It is understood that:

  1. You may not represent an outside employer as an employee of the university.

  2. Any views you may express on behalf of an outside employer do not necessarily reflect the views of the university.

  3. The name of the university and/or your official capacity at the university cannot in any way be used in support of any position you may take in behalf of an outside employer. It is further understood that you have familiarized yourself with the provision of Louisiana Revised Statutes 42:1101 et seq. relative to outside employment, Louisiana Revised Statutes 42:61 et seq. relative to dual office holding and the policies on these subjects as defined in the Faculty and Staff Handbook of McNeese State University, as well as "Rules" of the University of Louisiana Board of Supervisors (PPM FS-III.VII.-I). Copies of these documents are available for review in the University Library and Web site, Personnel Office, and in the offices of each Department Head and Dean.

I hereby affirm that the information in this form (and attached statements) is accurate to the best of my knowledge as of the date listed below, that I have read and understand my obligations under the University’s Policy on Conflict of Interest and Conflict of Commitment, and that I will comply with the conditions and restrictions imposed by the University to manage, reduce, or eliminate conflicts of interest or conflicts of commitment. (R.S. 14:133 Filing a false public document) I commit to providing an updated form to my immediate supervisor whenever a significant change occurs in the information I have provided.

Employee's Signature

Signature and Date lines

Immediate Supervisor Signature block