FOR USE BY VICE CHANCELLOR FILE NO. ______
    FORM B approval necessary:
    [ ] YES [ ] NO

    LCTCS POLICY No. 6.018 FORM A Disclosure of Outside Employment

    Louisiana Community and Technical College System
          		Delgado Community College Proposed Outside Employer and Location of Same:
     
     
    LCTCS Policy No. 6.018 requires that all full-time employees of the LCTCS comply with its provisions and disclose, on an annual basis, all outside employment as defined within it. Completion of Form A is required for each outside employment event; blanket approvals will not be granted. If the approval of the Chancellor or System President is required, Form B must be attached. Employees are required to become familiar with Policy No. 6.018 before completing this form.
    EMPLOYEE DISCLOSURE

    Employee Name:
          		Department:

    Describe proposed activity below.
     
     
    1. My outside employment would be with an entity currently doing or actively seeking to do business with my unit at ___________________________________________. [ ] Yes
    [ ] No
    2. My outside employment would involve teaching, which results in LCTCS student credit, will be conducted on LCTCS time or will utilize LCTCS property or services. [ ] Yes
    [ ] No
    3. My outside employment would involve my providing professional, personal, consulting and social services to a department, commission, council, board, office, bureau, committee, institution, agency, government, corporation, or any other establishment of the Executive Branch of the State of Louisiana. [ ] Yes
    [ ] No
    4. I am collaborating with or on special assignment to a unit within the LCTCS and/or an LCTCS institution with which the company is doing or is seeking to do business. [ ] Yes
    [ ] No
    5. My outside employment would yield results which advance a theory or practice in my field. [ ] Yes
    [ ] No
    6. My outside employment would result in my receiving compensation to assist in the passage or defeat of state legislation during the fiscal year in which the legislation was pending in the legislature. [ ] Yes
    [ ] No

    I will explain to the proposed outside employer that: (1) I do not represent said outside employer as an employee of the LCTCS in any manner, (2) any views I express on behalf of an outside employer do not necessarily reflect the view of the LCTCS, Delgado Community College, and/or any LCTCS institution, and (3) in no way the name of the LCTCS and/or Delgado Community College nor my official LCTCS capacity be used in support of any position I may take on behalf of said outside employer. Furthermore, I certify that LCTCS personnel, laboratories and equipment will not be used in connection with outside employment other than as provided in LCTCS Policy No. 6.018. I understand approval is required on an annual basis thereafter, as long as outside employment is applicable.
     
    My signature attests to my understanding of and compliance with LCTCS Policy No. 6.018.
     
    Signature:                                                                       Date: ________________________
     
    ADMINISTRATIVE REVIEW
    Indicate your agreement or disagreement with the following statements.

    7. The proposed duties ordinarily would be performed as part of the public service portion of the employee’s duties and responsibilities Immediate Supervisor :
     
    Intermediate Supervisor:
    (if applicable)
    Appropriate Vice Chancellor:         		[ ]Yes [ ] No
     
    [ ]Yes [ ] No
     
    [ ]Yes [ ] No
    8. The proposed activity more appropriately would be accomplished by a contract through the LCTCS and/or Delgado Community College. Immediate Supervisor :
     
    Intermediate Supervisor:
    (if applicable)
    Appropriate Vice Chancellor:         		[ ]Yes [ ] No
     
    [ ]Yes [ ] No
     
    [ ]Yes [ ] No
    9. The legal entity for which the outside employment is proposed has substantial economic interest which may be materially affected by the way in which the employee performs his or her duties and responsibilities as an LCTCS employee. Immediate Supervisor :
     
    Intermediate Supervisor:
    (if applicable)
    Appropriate Vice Chancellor:
         		[ ]Yes [ ] No
     
    [ ]Yes [ ] No
     
    [ ]Yes [ ] No
    10. The outside employment involves public policy. Immediate Supervisor :
     
    Intermediate Supervisor:
    (if applicable)
    Appropriate Vice Chancellor:         		[ ]Yes [ ] No
     
    [ ]Yes [ ] No
     
    [ ]Yes [ ] No

    ADMINISTRATIVE APPROVALS
    If the answer is YES to either question (3) or (10), 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 the ______________________.

    Immediate Supervisor
     
    Signature: Date:     		[ ] Recommended [ ] Not Recommended
    Intermediate Supervisor (if applicable)
     
    Signature: Date:     		[ ] Recommended [ ] Not Recommended
    Appropriate Vice Chancellor
     
    Signature: Date:     		[ ] Recommended [ ] Not Recommended

    ACTION BY CHANCELLOR
    Chancellor Signature:

    [ ] APPROVED [ ] DISAPPROVED [ ] Forwarded through Chancellor for Action by
    System President

    [ ] Returned to employee for compliance with LCTCS Policy No. 6.018 requirements requiring approval of Chancellor.
    All reviewing administrators hereby certify that they have read and are familiar with the Louisiana Code of Ethics and that approval of this outside employment does not knowingly violate the Code of Ethics, PM-11 or any other rule or regulation of the LCTCS, Delgado Community College, or any LCTCS institution.


     
     

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    LCTCS Policy No. 6.018 Form “A” Disclosure of Outside Employment:
    Page 1 of 2 - Delgado Form (6/21)