Attachment 2
University of California
Compensated and Uncompensated Outside Professional Activities
Review, Approval and Reporting of Senior Management Group (SMG) Activities
Forms required to be submitted by each SMG member for approval of activities
1. Justification Letter (NEW) – Provides information on all new activities being requested by SMG
member. Justification must include paragraph or statement describing benefits that accrue to
the University for the service being requested. Must be completed for all service, whether
compensated or uncompensated service, for-profit or not-for-profit organizations. Since this is
a new requirement, all SMG would be required to complete this form for all service proposed in
2016, and then new service each year thereafter.
2. Approval Request Form – Provides details on proposed service each year and new service, as
required. This form collects details on all proposed activities including whether the service is
compensated or not; the name of the organization and whether it’s non-profit; a description of
the service and anticipated hours and compensation, including cash, equity and any deferred
compensation. The SMG member certifies that the information is accurate and that the service
is compliant with the California Political Reform Act and the Regents’ Policy on OPA. The
Approval Authorities, including the immediate manager, plus the Chancellor, President or
Chairman of the Board of Regents, as appropriate, review and approve the requests.
3. Detailed Information Form – Provides details on compensated activity for all new service, as
required. This form collects details on newly proposed compensated activities and requires
disclosure of the entity name, nature of business and its location, as well as proposed income
including payments, loans, gifts, travel and expense reimbursements. This form also requests
disclosure of investment in the entity and whether it constitutes more than 10%
ownership/interest. It also requests information on possible Conflict of Interest issues and
requires description of these.
Process for Review and Approval
If the Regents approve the proposed changes to the policy, including the new Justification Letter, each
SMG member will be required to provide a completed Justification Letter describing the benefits to the
University for each service performed in 2016.
Each year, the SMG will submit the Approval Request Form. If there are new compensated activities the
Detailed Information Form and, for new compensated or uncompensated activities, the Justification
Letter will be required to be submitted to the Approval Authorities, including the Chancellor, President
or the Chairman of the Board of Regents, as appropriate, for their review and approval prior to
undertaking or announcing any service.
Reporting – At the beginning of the calendar year the SMG member reports details on each activity,
compensated and uncompensated, performed during the preceding calendar year, including the amount
of time spent, the amount of money and other forms of compensation received. This report is posted
publicly at: http://compensation.universityofcalifornia.edu/reports.html
SENIOR MANAGEMENT GROUP MEMBER OUTSIDE PROFESSIONAL ACTIVITIES (OPA)
2016 OPA PRE-APPROVAL FORM
Comp
Service
(Y/N)
Name of
Organization
Non-Profit/
For Profit
Description of
Service
Anticipated Hours of
Service/Year
During
Outside
Bus Hours Bus Hours
Vacation
Hours to Debit
(For Serv During
Bus Hours Only)
Anticipated
Compensation
Cash
Deferred or
Comp
Other Comp
Grant
Type
Long-Term Incentives
No. Shares Strike Price Vesting
Granted
per Share Schedule
We are requesting additional information regarding some OPAs on the Detailed Information Form. You do not need to complete the Detailed Information Form if you are seeking pre-approval
for an OPA that you participated in last year, as long as your role and compensation in connection with that OPA has not changed. You also do not need to complete the Detailed Information Form
if you are seeking pre-approval for an OPA with a 501(c)(3) entity, as long as you do not receive income, honorarium, loans, gifts, or payments of any sort from the entity (other than travel
reimbursements or per diem). Please complete the attached Detailed Information Form for any other kind of OPA (e.g., a new OPA with a for-profit, a 501(c)(6) entity, or a new paid OPA with a
501(c)(3) entity).
Employee:
1. I certify that the information on this form and the attached Detailed Information Form(s), if any, provides an accurate description, to the best of my ability, of the OPA(s) I propose to engage in during calendar year
2016 and that these activities are permissible under policy.
2. I understand that it is my responsibility to comply with the California Political Reform Act and that I should seek advice if I have questions.
Click here to view the Act
3. I certify that I have complied with University of California Regents Policy 7707 - Senior Management Group Outside Professional Activities.
Click here to view the Policy
Employee Name: _________________________________
(please print)
Employee Signature: ______________________________
Date: _________________
Immediate Supervisor: I certify that I have reviewed the OPA above, that it is permissible under policy, and that I approve.
Supervisor Signature: ______________________________
Date: _________________
Second-Level Approval Authority:
Print Approval Authority Name
Signature
Date
Notes:
Click here to see your location's Conflict of Interest Coordinator
The SMG member's responsibility and the supervisor's (approving authority) responsibility are described in the Policy, titled Senior Management Group Outside Professional Activities, and specifically in Sections III.A.1 and III.A.2.
5/19/2016
Senior Management Group Outside Professional Activities (OPA)
Detailed Information Form
Please refer to the SMG OPA Pre-Approval Form to determine whether you must complete this form for
your proposed OPA.
1.
2.
3.
4.
5.
Employee name: ___________________________________________________________
Name and website of entity: _________________________________________________
Nature of entity’s business: __________________________________________________
Is the entity located in California?  Yes  No
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: _____
Loans
Last 12 mos: _____ Next 12 mos: _____
Gifts
Last 12 mos: _____ Next 12 mos: _____
Travel reimbursements
Last 12 mos: _____ Next 12 mos: _____
Expense reimbursements
Last 12 mos: ______Next 12 mos: _____
Per diem
Last 12 mos: ______Next 12 mos: _____
6. If the entity is non-profit entity, what kind of non-profit is it?
 501(c)(3)  Governmental entity  Other: ____________
7. If the entity is a for-profit 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. 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?
 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 for-profit or is located outside of
California. If you have any questions now, please contact your location’s Conflict of Interest Coordinator.