Outside Activities Report Submission Form

University of Wisconsin System

Unclassified Staff (Faculty, Academic Staff, and Limited Appointees) Report on Outside Activities and Interests
(As required under Section UWS8.025 Wisconsin Administrative Code)

Fill in the fields online related to your activities during the last calendar year (see UWS Guidelines for Reporting Outside Activities.
These forms are to be on file in Human Resources no later than April 30, 2014
If you have questions, contact Human Resources via AskHR.

Name:

 

Department/Unit:

  

Reporting Year:

 

Campus ID/Payroll ID:

 
  i.e. 2013  
    

Supervisor's Email:

   

Unclassified Staff Appoint Type:

   
   
   
 

Percent University Appointment:

 

   
   
  
I have read the Guidelines and do not have any remunerative outside activities in my field of interest to report. 


 Name:

 

 Date:

 

By typing your name you are digitally signing this form. Your signature indicates your acknowledgment.


A. Remunerative Relationships

   
   
 
I have received net remuneration for professional outside activities in my field of professional interest (e.g., consulting, research, teaching, writing, etc.). 
List below the name of the organization or business, type of activity (e.g., consulting, teaching, etc.) and the aggregate amount of time spent (days) in the activity, and whether you received $5000 or more from a single source.

 Name of Business*
or Organization

 Type of Activity

 Time Spent (days)

 Indicate if $5000
or More From a 
Single Source

       
       
       
 I have received compensation from a nongovernmental sponsor of university research, teaching, or training for which I am a principal investigator. 
   
   
 

 Name of Sponsor:

                                                              


B. Offices and Directorships

Identify below any business or other organization related to your field of academic interest or professional specialization for which you or your immediate family served as an officer, director, or trustee. No identification need be made of professional societies, trusts, or charitable, religious, social, community service, or political organizations.

 Name of Business/Organization

 City and State

 Position Held

     
     
     


C. Ownership Interests

List below any business or other organization related to your field in which you or your immediate family individually, or in aggregate, owned or controlled at least 10% of the outstanding equity.

 Name of Business/Organization

 City and State