Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
DUAL EMPLOYMENT FORM Employee Name: _____________________________________ Prepared By:
Dual Employment Period (1 yr. maximum) From: _____________________ To:
Instructions: Please fill out all information below and obtain all signatures required.
Employer #1:
Employer #2:
RCUH Project Name:___________________ UH Project Name:
Source of Funds: Federal State (circle one): G-Fund or Other
Project # _______________ FTE: _______%
Employee Job Title: _____________________________________________________________________ Detailed Work Schedule (days & hrs): _______________________________________________________
RCUH Project Name:___________________ UH Project Name:
Source of Funds: Federal State (circle one): G-Fund or Other Other: ______________________ Project # _______________ FTE: _______%
Employee Job Title:
Detailed Work Schedule (days & hrs):
______ Other: ______________________
The undersigned hereby acknowledges the dual employment between both Employers listed above. The undersigned hereby acknowledges that they have read and understand the RCUH Dual Employment Policy, Section 3.250, and agree to abide by its provisions. This dual employment arrangement will be monitored by both programs to ensure that no conflict of interest, in work hours or performance shall occur as a result of this agreement. Any change in employment status relative to either appointment shall be reported to the RCUH HR Dept. in advance by submitting a new Dual Employment Form. Any special comments may be noted by attaching an additional sheet.
Employer #1:
PI Signature: _________________________________________Date: _____________ Print Name: ___________________________________________________________ FO Signature: ________________________________________Date:_______________ Print Name: ___________________________________________________________ Dean/Grad Dept. Chair Signature (see*):_________________________Date:_________ Print Name: __________________________________________________________
Employer #2:
PI Signature: _________________________________________Date: _____________ Print Name: ___________________________________________________________ FO Signature: ________________________________________Date:_______________ Print Name: ___________________________________________________________ Dean/Grad Dept. Chair Signature (see*):_________________________Date:_________ Print Name: __________________________________________________________
Special Instructions: *Dean/Director signature required for: 1) appointments exceeding 100% combined FTE or 2) involves faculty positions *Graduate Department Chair signature for: 1) UH Graduate Assistant positions
RCUH Director of Human Resources or Designee: ___________________________________________________________________________ Print Name/Signature Date
RCUH Form E-5 (revised 03/11, 07/11, 02/16)