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Senior Management Group Outside

senior management group outside professional activities (opa) detailed information form (for compensated activities only) please
30 Jan, 2023
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Senior Management Group Outside Professional Activities (OPA)
Detailed Information Form (for Compensated Activities only)
Please refer to the SMG OPA Approval Form to determine whether you
must complete this form for your proposed OPA.
1.
Employee name:

2.
Name and website of entity:

3.
Nature of entity’s business:

4.
Will your activity involve international travel paid by the
entity?  Yes  No
5.
Please indicate the actual value of any payments or gifts that you
have received from this entity in the last 12 months and the
highest total value of any payments or gifts that you anticipate
receiving from this entity in the next 12 months.
Income or payments, including honoraria
Last 12 mos: Next 12 mos:
Travel reimbursements
Last 12 mos: Next 12 mos:
Loans
Last 12 mos: Next 12 mos:
Expense reimbursements
Last 12 mos: Next 12 mos:
Gifts
Last 12 mos: Next 12 mos:
Per diem
Last 12 mos: Next 12 mos:
6.
If the entity is nonprofit entity, what kind of nonprofit is it?
 501(c)(3)  Governmental entity  Other:
7.
If the entity is a forprofit entity, please answer the questions
below.
a.
Will you serve the entity as a director, officer, partner,
trustee, employee, or in some position of management?  Yes  No
If yes, describe:

b.
Do you have an investment in the entity or do you anticipate
acquiring one?
 Yes  No If yes, describe the investment and estimate its fair
market value:


c.
Does your investment result in you having a 10% or greater
interest in the entity?
 Yes  No
8.
Does the entity do business with the University or anticipate
doing business with the University?
 Yes  No
9.
Do you anticipate making, participating in making, or influencing
any University decisions regarding the entity or any University
decisions that could have a financial effect on the entity?
Examples of decisions regarding the entity include, but are not
limited to areas such purchasing, contract approval, real estate,
investments.
 Yes  No If yes:
a.
Describe these decisions:


b.
Indicate whether you would be able to refrain from involvement in
such decisions if necessary:


Employee Signature: Date:

We may need to contact you with additional questions, particularly if
the entity is forprofit or there is expected international travel. If
you have any questions now, please contact your location’s Conflict of
Interest Coordinator.

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