Form for Review/Approval of Honorary Degrees

Office of the General Counsel, Ethics Division

Department of Health and Human Services

I. Employee Information

Agency Use Only
Applicant's Name, Title, and Agency Address (please print)

Date
Office Telephone Number

( ) - Ext.

II. Honorary Degree Information
Name of Institution of Higher Education (as defined at 20 U.S.C. 1141)

Date Degree Conferred

Answer the following questions. Append as attachments any documentation supporting the application for approval. Sign and date the form in the space provided.

1.	Are any matters or controversies (e.g., lawsuits, investigations, disputes) pending that involve the institution as a offering
the degree and the employees component or agency that would militate against, or otherwise should be considered in	connection with, approval of receipt of the honorary degree?

Yes. If yes, describe the pending matters in the space provided.

No.

2.	Would the timing of the award of the degree cause a reasonable person to question the employee's impartiality in a
matter affecting the institution?

Yes. If yes, describe the circumstances.

No.

3.	Does the employee agree: (1) to be disqualified from specific party matters involving the institution as a party or a
representative of a party from the date of approval through the date the honorary degree is conferred; and to refer matters	involving the institution offering the honorary degree to the employee's supervisor (or the employee's deputy, if
appropriate) during the period of the employee's disqualification?

Yes.

No.

Employee/Authorized Representative Signature

Date

Revised April 1999 - Previous Editions Obsolete

III. Official Determination

The honorary degree is approved, subject to the following conditions:	None	Conditions (specify)

The honorary degree is disapproved.

Specified Conditions (if any)

Agency Ethics Official Signature

Date

IV. Notices

PRIVACY ACT STATEMENT

Section 7301 of Title 5 of the U.S. Code and Executive Order 12674, as implemented by Section 2635.204(d) of Title 5 of the Code of Federal Regulations, authorize the collection of this information. Disclosure of this information is mandatory for employees seeking authorization from an agency ethics official to accept an honorary degree, pursuant to Section 2635.204(d)(2) of Title 5 of the Code of Federal Regulations. The primary use of this information is to allow HHS ethics officials to make necessary determinations concerning employee requests to receive honorary degrees. Additionally, this information may be used: (1) by the Office of Personnel Management, Office of Government Ethics, Merit Systems Protection Board, Office of the Special Counsel, Equal Employment Opportunity Commission, Federal Labor Relations Authority, Federal Service Impasses Panel, Federal Mediation and Conciliation Service, and an arbitrator, in carrying out their functions; (2) by an appropriate federal or foreign agency charged with investigating or prosecuting violations of, or implementing, the law, in the event there is an indication of a violation or potential violation of civil, criminal or regulatory law; (3) by a federal, state, or local agency maintaining enforcement records or other pertinent records, such as current licenses, if necessary to obtain a record relevant to an agency decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other benefit; (4) by a state or local agency charged with investigating or prosecuting violations of, or implementing, the law, in the event there is an indication of a violation or potential violation of civil, criminal or regulatory law; (5) by federal agencies with power to subpoena other federal agencies' records; (6 ) by private firms with which the Department may contract for the purpose of collating, analyzing, aggregating or otherwise refining records; (7) by a Congressional office, pursuant to an inquiry made at the request of the individual who is a subject of the record; (8) and by the Department of Justice in defense of litigation.

CERTIFICATION

The signature of the employee/authorized representative in Part II of this form certifies that the statements made and information provided on this form are true, complete, and correct to the best of the individual's knowledge. Failure to provide the requested information will result in the denial of the request for approval. Falsification of information required to be reported for this purpose may subject the employee to disciplinary action by the employing agency or other appropriate authority. Knowing and wilful falsification of information required to be reported may also subject the employee to criminal prosecution.