Before undertaking paid outside work, members of staff Once completed the document should be filed in the must complete this form and have it approved by their staff members personal file with local Human Resources. Head of Department. Detailed guidelines on paid outside Enquiries regarding this form can be made to local work can be found at: http://go.unimelb.edu.au/s56 Human Resources.
All fields on this form which are marked with an asterisk
(*) are mandatory.
1. EMPLOYEE INFORMATION
Employee No Academic Level
Family Name Given Names
Organisation Unit
2. DETAILS OF PROPOSED PAID OUTSIDE WORK
NOTE: Approval must be sought for all paid outside work proposed to be undertaken by a full time or part time
academic staff member which is associated in some way with his or her employment with the University of Melbourne. Short explanation of nature of
work to be undertaken
Dates on which work will be
undertaken
Please advise any conflict of interest that may arise
between the proposed work and your duties for the
University. Please specify proposed arrangements to manage the conflict.
3. INSURANCE COVER
I have the necessary insurance and level of insurance cover in place for professional indemnity and third party liability to provide cover for the nature of the outside work I propose to undertake. I agree these will remain in
force for such time as is necessary to maintain cover, including “run off” insurance. I agree to provide a certificate of currency as required. OR
Alternate arrangements for insurance cover as approved by the Vice-Principal and General Counsel are in
place.(Approval attached)
4. TIME RELEASE (Full-time academic staff only)
I seek time release of days to undertake paid outside work
The following arrangements have
been made to cover my teaching or
other duties
Time commitment from to
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5. ACKNOWLEDGEMENTS OF RISKS AND RELEASE FROM LIABILITY (Indemnification)
I acknowledge that I am undertaking the paid outside work in my personal capacity and not in my capacity as an employee or agent of the University. In consideration of the University agreeing to my application for approval to undertake paid outside work, I acknowledge that I have no claim or rights enforceable against the University now or in the future arising as a result of any injury, accident, illness, death or damage to or loss of property suffered by me or members of my family or persons for whom I am otherwise legally responsible. I fully and unconditionally release, to the extent permitted by law, the University from any such liability should it transpire for any reason that such a claim or right is enforceable by me against the University on any basis whatsoever.
I have fully assessed and understood the personal and legal liability risks, where relevant, associated with my undertaking this paid outside work, and I have been given an opportunity to obtain independent professional and other
advice where I have considered it necessary or appropriate to do so, including any governmental warnings or advices relating to travel to foreign destinations.
Signature of Date
Applicant
6. APPROVAL BY HEAD OF DEPARTMENT
The Head of Department may approve time release of up to 13 days per quarter
The work to be undertaken is compatible with the professional status of the applicant
Time release being sought will not interfere with the proper discharge of the applicant’s University duties
And, either/or:
There is no conflict of interest between the work to be undertaken and the applicant’s University duties.
There is a conflict of interest between the work to be undertaken and the applicant’s University duties and the
following arrangement have been made to manage that conflict:
Arrangements have been made for any proposed use of University facilities, equipment or services and will be
charged to the applicant in accordance with University policy.
All necessary insurance, indemnity and third party release arrangements are in place and, where necessary, have
been cleared with the Vice-Principal and General Counsel.
The work proposed is consistent with the staff member’s obligations under the University’s Intellectual
Property policies.
Signature of Name
Head of Dept
Date (Level 2 Delegation)
7. APPROVAL BY DEAN (where applicable)
The Dean must approve all applications for time release which are for more than 13 days per quarter which
are averaged over two quarters. Deans have the delegation to approve paid outside work for Heads of Departments.
The Provost has the delegation to approve paid outside work for Deans.
Signature Name
of Dean
Date (Level 3 Delegation)
PRIVACY INFORMATION
Information collected on this form will become part of It will be stored securely and only used or released in
your employment record. accordance with the University’s privacy policy which is
available from: www.unimelb.edu.au/unisec/privacy.
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