UNIVERSITY OF MASSACHUSETTS DARTMOUTH
Additional Compensation Request Form for Faculty
and Staff Engaged in Instructional Activities
Duties for this assignment________________________________________________________________________________________
_____________________________________________________________________________________________________________
Employee’s Name ________________________________________________ Empl ID _____________________________________
Title ___________________________________________________________ Department __________________________________
This additional assignment is funded by ___________________________________________________________________________
(source of funds – name of grant, fees, etc.)
HR Account Code ___________________________
Project/Grant number___________________________________
Salary $______________________per hour/day/week
Total of __________ hours; __________ days; __________ weeks.
(for this assignment)
(circle appropriate cycle)
How is salary to be paid?
Stipend $______________per week/per day
OR
Day/Hourly Rate $____________________
Start Date _________________________
$ Amount Allocated Through June 30th
End Date _________________________
$ Amount Allocated From July 1st To Appt End Date $______________
Total $ Amount Allocated For Appt
$______________
$____________
Is this additional work assignment performed during the employee’s usual work days/hours?
*YES ______ NO ______
*If YES, employee must complete a STATEMENT OF NON-CONFLICT, signed by EMPLOYEE’S department head /
supervisor and forward the Statement of Non-Conflict with this form.
_____________________________________________________
Signature of Individual Exercising Budgetary Control
Approvals:
Signature
Signature: Department Head/Dean
Department Head
Date
Date
______________________________
Date
Signature: Division Head
Dean (Required for Faculty)
Date
Date
Division Head (Required for Staff)
Date
FORWARD COMPLETED FORM TO: OFFICE OF HUMAN RESOURCES, Room 202, Administration Building
FOR OFFICIAL USE ONLY:
Comments: ________________________________________________________________________________________________
HR: _______________________________________
Date ___________________
Budget: ____________________________________
Date ___________________
Payroll: ____________________________________
Date ___________________
Note: Additional assignments must not be in conflict with the University’s Affirmative Action hiring policy.