Research Corporation of the University of Hawaiʻi

1
Research Corporation
of the University of Hawai‘i
Human Resources Department
RCUH EMPLOYMENT FORM (MULTIPLE POSITIONS)
Employer #1
Employer #2
Employer #3
Employer #4
1. Last Name: __________________________________________________
2. First Name: ______________________________________
3.M.I.: _____________________
4. Employment Period: From: ___________________________________________ To:____________________________________________________
5. Agency (ie. UH, RCUH, Dept): __________________________ Project Name: _________________________________________ Project#: _____________________________________________
6. Employee Job Title: ________________________________ PI Name: __________________________________________ Work Schedule: _____________________________________
7. FTE: _______%
8. Source of Funds: Federal State Other: _______________________
9. Agency (ie. UH, RCUH, Dept): __________________________ Project Name: _________________________________________ Project#: _____________________________________________
10. Employee Job Title: _______________________________ PI Name: __________________________________________ Work Schedule: _____________________________________
11. FTE: _______%
12. Source of Funds: Federal State Other: _______________________
13. Agency (ie. UH, RCUH, Dept): _________________________ Project Name: _________________________________________ Project#: _____________________________________________
14. Employee Job Title: _______________________________ PI Name: __________________________________________ Work Schedule: _____________________________________
15. FTE: _______%
16. Source of Funds: Federal State Other: _______________________
17. Agency (ie. UH, RCUH, Dept): _________________________ Project Name: _________________________________________ Project#: _____________________________________________
18. Employee Job Title: _______________________________ PI Name: __________________________________________ Work Schedule: _____________________________________
19. FTE: _______%
20. Source of Funds: Federal State 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 anew Dual Employment Form. Any special comments may be noted by attaching an additional sheet.
21. Employer #1
PI Signature: : _____________________________________Date: _____________
Print Name: _______________________________________________________
FO Signature: ____________________________________Date:_______________ Print Name: _______________________________________________________
Dean Signature (see*):_______________________________ Date:_____________ Print Name: _______________________________________________________
22. Employer #2
PI Signature: : _____________________________________Date: _____________
Print Name: _______________________________________________________
FO Signature: ____________________________________Date:_______________ Print Name: _______________________________________________________
Dean Signature (see*):_______________________________ Date:_____________ Print Name: _______________________________________________________
23. Employer #3
PI Signature: : _____________________________________Date: _____________
Print Name: _______________________________________________________
FO Signature: ____________________________________Date:_______________ Print Name: _______________________________________________________
Dean Signature (see*):_______________________________ Date:_____________ Print Name: _______________________________________________________
24. Employer #4
PI Signature: : _____________________________________Date: _____________
Print Name: _______________________________________________________
FO Signature: ____________________________________Date:_______________ Print Name: _______________________________________________________
Dean Signature (see*):_______________________________ Date:_____________ Print Name: _______________________________________________________
Special Instructions: *Dean/Director signature required for: 1) appointments exceeding 100% combined FTE or 2) involves faculty positions
RCUH Form E-5a
Revised 10/10/02, 01/08/09, 07/06/11, 04/21/16