DO S&S - Agreement Submission

DO S&S - Agreement Submission

Fund Number*

Department Number*

Department Name*

Department Contact Name*

Department Contact Email*

S&S Fund Director Name*

S&S Fund Director Email*

S&S Fund Director UCLA Employee ID*

S&S Fund Director Work Title*

S&S Fund Director Department Code*

Agreement Type*

Select

File Upload*

The agreement should be attached as a Word document to facilitate DO review.

Drag and drop files here or

External Client Business Name*

External Client Business Contact Email*

External Client Business Address*

External Client Business Country*

Name of Authorized Signatory*

Charles Hajek

Email of Authorized Signatory*

charleshajek@mednet.ucla.edu

Is this a current/past customer or potential new customer?*

Select

Does the proposed agreement involve the provisions of goods or services to a business entity in which university employee has a financial interest?*

A financial interest consists of a direct or indirect investment worth $2000 or more; any source of income to the employee(s) aggregating $500 or more provided or promised in the preceding 12 months; or a position in a business entity as a director, officer, partner, trustee, employee, or member of management.

Select

Did the university employee(s) with the financial interest make, participate in making, or attempt to influence the proposed UC decision to provide goods or services?*

"Influence" contact with a campus official for the purpose of affecting the decision.

Select or enter value

Does the proposed agreement involve the financially interested individual(s) teaching or research responsibilities?*

Select

Is the proposed agreement with a business entity of which an employee or the employee's near relative owns 10% or more?*

"Near Relative" means spouse, child, parent, brother, sister, son-in-law, brother-in-law, father-in-law, mother-in-law, and step relatives in the same relationship. It also includes a domestic partner in one of the foregoing relationships.

Select

Does the employee with the 10% or greater ownership interest (or whose near relative has a 10% or greater ownership interest) have teaching or research responsibilities?*

Select

Does the proposed agreement involve a commitment of time by an employee?*

Select

Is the proposed time commitment by the employee consistent with his/her percentage time commitment to the university and/or other contractors?*

Select

Does the proposed agreement involve a commitment of university facilities?*

Select

Is the proposed commitment of university facilities consistent with the commitment of these facilities to the university and/or other contractors?*

Select

Please provide additional explanation as required.

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