Employee Name:	Job Title	DCF Work Location

My Current work schedule is:

Week 1	Friday	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday
Time In
Time Out
Week 2	Friday	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday
Time In
Time Out

Secondary Employer Information

Name of Secondary Employer:
Address:	City	State	Zip Code
Title of Position Sought:
Start Date	End Date
Duties to be Performed:
Work Schedule:
Week 1	Friday	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday
Time In
Time Out
Week 2	Friday	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday
Time In
Time Out
Does the Secondary Employer receive funds in whole or in part from DCF? _____Yes _____No If yes, explain:
Does the Secondary Employer provide services to former or current DCF clients? _____Yes _____No If yes, explain:
Does the position with the Secondary Employer involve more than incidental contact with former or current DCF clients? _____Yes _____No If yes, explain:
I certify that no conflict of interest exists with this secondary employment and that the secondary employment will not interfere with the performance of my duties and responsibilities or my current work schedule or, including but not limited to, required overtime.
Employee Signature:	Date:
Agency Human Resources Administrator Action: _____Approved _____ Denied.
Reason for Denial/Comments:
Agency Human Resources Administrator Signature:	Date: