Note: Parts IV and V must be completed before the form is sent to Ethics and Integrity staff. Once the form is completed and signed, send the HHS 520 form to your supervisor. It is your responsibility to ensure that the form reaches the appropriate people for approval and approval. You should not participate in the external activity until you have received a notification from ethics and integrity staff that your form has been approved. 12. Supervisor Contact Information: Provide full contact information You can also use the form below, write a letter or fax. c) Select the appropriate checkbox to specify when the activity will run. If the work is not performed completely outside normal working hours, you must explain what type of leave will be taken. Since the activity is carried out on your private property, the official time should not be used to perform any part of the activity.
Form HHS 520 is available on the FDA Ethics and Integrity Staff intranet site (see link at the bottom of the page). Please note that the January 2006 version of FORM HHS 520 must be used. All previous versions are deprecated. 4. Contact Information: Provide complete information on how to contact an employer or external organization. If no information is available for a block, please provide ”None” or ”N/A” Submit a ”Request for Hearing by an Administrative Judge” form to appear before a judge to plead your case. SSA-3288: ”Consent to Disclosure of Information” 62 At Headquarters, the Associate Commissioner of Regulatory Affairs signs Part V. Form HHS 520 should not be sent from the field to the Associate Commissioner of Regulatory Affairs unless the application for approval is for the RFDD or DD.) (d) Indicate whether the remuneration comes from an HHS grant, contractual agreement or other source of HHS funding, or whether the services to be provided are related to an activity funded by HHS.
If you do not receive compensation, the answer may be ”None”. HHS employees may not engage in paid employment as defined in 5 CFR 2635.603(a) with respect to a particular activity funded by a grant, contract, cooperation agreement, research and development cooperation agreement, or other funding mechanism permitted by law. 7. Financial Statement Filing Status: Specify the financial disclosure form you must submit (PUBLIC SES level SF-278 or Confidential EMB Form 450) or ”NONE” if you are not submitting a financial information report. If you have additional evidence relating to the time elapsed on or before the date of the hearing decision, you must inform it or submit it to the Board of Appeal. If you have a representative, your representative must help you obtain the evidence, unless the evidence falls under an exception. You may also submit other additional evidence to the Appeal Board. If you need more time to present evidence or legal arguments, you must now request an extension of time in writing. This ensures that the Appeal Board has the opportunity to consider additional evidence before taking action.
If you do not present legal evidence or arguments now or within a time limit granted by the Appeal Board, the Appeal Board will take action based on the evidence currently on file. Contact person: ListName and title of the contact person. If you are self-employed, provide your contact information. If you do not agree with our reconsideration decision on your claim for benefits, you can request a hearing before an Administrative Judge (ALJ). To request a hearing, you can use this form or write a letter. No prior authorization is required to participate in a political, religious, social, fraternal or leisure organization, unless the position requires the provision of professional services or the activity is carried out for remuneration. You must inform us or submit evidence no later than 5 business days before the scheduled hearing. Failure to comply with this requirement may result in the ALJ refusing to consider the evidence.
(f) provide all information on the previous remuneration of the same external entity during the last six years. If there is no prior case or compensation, the answer may be ”none”. To share certain private information with your representative, 62 to 63 employees who wish to participate in an external activity that requires prior approval must submit an HHS 520 ”Request for Authorization of External Activities” form. An HHS 520 form is also required for a review of an existing activity if the circumstances of the employee`s official duties or the nature of the external organization have changed significantly. or for the renewal of an existing activity. All applications for approval, review or renewal must be submitted within a reasonable time before the start of the activity. Submit the completed form to your local Social Security office or appeal board, 5107 Leesburg Pike, Falls Church, VA 22041-3255. If you have any questions, you can call us toll-free at 1-800-772-1213 Monday to Friday from 7.m a.m to 7 p.m. .m.m. If you are deaf or hard of hearing, you can call our TTY number 1-800-325-0778. *Note: Most of these forms are available on the Social Security website in www.ssa.gov. 9.
Office contact information: Provide complete information. If you have nothing to report in a block, please specify ”None” or ”N/A” from your supervisor. If no information is available, please provide ”None” or ”N/A” you may also need to complete Form SSA-1696, Appointment of a Representative, when appointing a representative. Your representative must also sign SSA-1696 before sending it to us. Submission Date: Enter the date the form was sent to your manager. 6. Travel: Check the appropriate box to indicate if it is a trip. Use the box below to insert the additional information requested. Submit to: After completing Parts I, II and III of the form, employees must provide the form to their supervisor to complete Part IV. At the end of the review, the supervisor will send the form to the Director of the Centre or the Assistant Centre to complete Part V (p.
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