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| **Form for Review/Approval of Honorary Degrees** |
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**Office of the General Counsel, Ethics Division**

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  **Department of Health and Human Services **
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**I.** **Employee Information**

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

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| Date |
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Office Telephone Number

( ) - Ext.

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

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Date Degree Conferred

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

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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.*

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Employee/Authorized Representative Signature

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**Revised April 1999 - Previous Editions Obsolete**

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| **III. Official Determination** |   |
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' The honorary degree is approved, subject to the following conditions:
" None " Conditions (specify)

' The honorary degree is disapproved.

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Specified Conditions (if any)

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Agency Ethics Official Signature

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| **IV. Notices** |
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**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.**