FILE NO. _______

POLICY No. 6.018 FORM B Disclosure of Outside Employment

Requiring Approval by Chancellor or System President

Louisiana Community and Technical College System

Baton Rouge, Louisiana

Delgado Community College

Proposed Outside Employer and Location of Same:

If outside employment requires approval by the Chancellor or the System President, the employee must follow the certification and contracting provisions of Policy No. 6.018 under the Approval Level section for outside employment. All required documents shall be attached to and made a part of this Disclosure Form before submission through administrative channels for review by the Chancellor. The following approvals must be obtained before engaging in the proposed outside employment and requested on an annual basis thereafter, as long as outside employment is applicable.

EMPLOYEE DISCLOSURE

Employee Name:

Department:

Proposed compensation to be received:

Date:

APPROVAL/CERTIFICATION BY CHANCELLOR

The outside employment activities are not within the course and scope of the employee’s duties to the college for which the employee is being compensated by the LCTCS and/or Delgado Community College.

The outside employment activities do not conflict, delay or in any manner interfere with instructional, scholarly and/or services which the employee is obligated to perform for the LCTCS and/or Delgado Community College.

The consulting activities to be performed are within the academic or professional discipline of the employee or are related to the area of expertise in which the employee is employed by the LCTCS and/or Delgado Community College.

Signature: ___________________________ _______________

Chancellor Date

OUTSIDE EMPLOYMENT INVOLVING PUBLIC POLICY

OR A STATE AGENCY

If the answer is YES to either question (3) or (10), on LCTCS Policy No. 6.018 Form A, the System President’s approval is required. If the answer is YES to any other question, the Chancellor’s approval is required. If all responses are NO, then outside employment may be approved by _________________.

Such approval is required on an annual basis thereafter, as long as outside employment is applicable.

[ ] APPROVED

[ ] DISAPPROVED

Signature: _____________________________ ________________

System President Date