Outside Employment Disclosure Form
For Management Personnel Plan (MPP) Employees1
Requirements: This form is to be completed as appropriate by MPP employees 1 pursuant to Section 42740 of Title 5, California Code of Regulations, even if completed at an earlier date.
Name: __________________________________________________ Position/Title: _________________________________________
Campus: _______________________________________________ Department: _________________________________________
Type of Disclosure (Check at least one box):
☐ Annual: The period covered is January 1, 20____, through December 31, 20____.
—OR— The period covered is _____/______/20____ (Time of hire or appointment) through December 31, 20_____.
☐ Time of Hire or Appointment Date: _______/_______/20_______
☐ Accepted outside employment: Outside employment accepted date: ______/________/20____
☐ Administrator request: The period covered is ______/________/20_____ through ______/________/20_____
—OR — Current outside employment beginning ______/________/20____
Outside Employment Status (Select one):
☐ I have outside employment to report (complete table below).
☐ I have no outside employment to report.
| Nature of Outside Employment Held | Number of Hours for Reporting Period | Expected Duration From/To | |
|---|---|---|---|
| 1 | |||
| 2 |
☐ I affirm that the information on this form is accurate to the best of my knowledge, that I have read and understand my obligations under the CSU’s policy on Outside Employment Disclosure, and that I will comply with the conditions and restrictions imposed by the CSU to manage, reduce, or eliminate conflicts of commitment/interest. I certify that my time commitment to the outside employer(s), if applicable, does not create a conflict of commitment/interest that would interfere with CSU work assignments and satisfactory performance. I also commit to providing an updated form to my immediate supervisor whenever a significant change occurs in the information I have provided. (Complete and sign below)
Employee Signature: ____________________________________________________ Date: ________________________________
Reviewed by:
Name: ______________________________________________ Date: ________________________________
Administrator’s Signature: ____________________________________________________________
If applicable, submit form and attachments to the independent review committee for additional review and approval. Submit completed form to HR.
1 For Vice Presidents and Executive employees, see the Outside Employment Disclosure Form for Senior Management Employees.
CO-HRM Rev. 6/2019
This HTML version was generated with AI assistance and may contain errors or omissions. The original approved PDF remains the official document of record. An alternative accessible format is available upon request from the document creator in accordance with Title II of the ADA.