OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 1 of 3 2015-16 Form for Neal Hermanowicz REPORTING PERIOD JULY 1, 2015 ENDING JUNE 30, 2016 Status: Submitted on November 12, 2017 In accordance with APM-671, all Compensation Plan participants are required to complete this form and submit for approval no later than October 31, 2016. Earnings threshold is 40% of your component or $40,000 - whichever is greater. The time threshold is 21 days per fiscal year. If you have question, please contact your department administrator. Faculty Name: Hermanowicz, Neal Academic Title: HS Clin Professor Hcomp - 1734 Appointment: School of Medicine Home Department: Neurology 5_1 6 7/3/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 2 of 3 1. Category 1 or II 9 Service Dates 0 of Days 3 Involved Student Name of Outside Entity 9 Role 9 Description of Services Provided 3 Income Earned 9 E: Income Retained 0 Additional Information Total of Days: 0 Total Income Earned: $0.00 Total Income Retained: $0.00 El did n_ot engage in Category I or activities. DI did engage in Category or activities and total income earned did exceed the earning threshold. Ell did engage in Category or activities and total income earned did exceed the earnings threshold (prior approval required). 5_1 6 7/3/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 3 of 3 I certify that have complied with the provisions of the University of California Health Sciences Compensation Plan, the School of Medicine Health Sciences Compensation Plan Implementation Procedures, and my departmental guidelines for the Plan regarding limitations on the retention of earnings, and time spent in Outside Professional Activities. I understand the Dean or his designee may require a copy of my IRS Form 1040, specifically Schedules A and C, and all W-Zs and 1099s, upon request, as verification of the above information. Note: Information disclosed herein is a public record under the California Public Records Act. Submitted By Hermanowicz, Neal Submission Date 11/ 12/2017 This signature affirms the form was received and approved. Approved By[ Approval Date :1 Files for Neal Hermanowicz Add File List of Participants Enter Scanned Copy Info Return Form to Faculty 1 5_l 6 7/3/2019 OPA I Of?ce of Academic Affairs I Susan and Henry Samueli College of Health Page 1 of 3 2016-17 Form for Neal Hermanowicz REPORTING PERIOD JULY 1, 2016 ENDING JUNE 30, 2017 Status: Submitted on November 12, 2017 In accordance with APM-671, all Compensation Plan participants are required to complete this form and submit for approval no later than November 1, 2017. Earnings threshold is 40% of your component or $40,000 - whichever is greater. The time threshold is 21 days per fiscal year. If you have any questions about the policies governing Outside Professional Activities, please contact your Department CAO. Faculty Name: Hermanowicz, Neal Academic Title: HS Clin Professor Hcomp - 1734 Appointment: School of Medicine Home Department: Neurology 6_17 3/26/2019 OPA I Of?ce of Academic Affairs I Susan and Henry Samueli College of Health Page 2 of 3 1. Category 0 VI Service Dates 0 I of Days 6 Involved Student Name of Outside Entity 9 Role Nature of Relationship 9 I I Description of Services Activities Provided 3 Income Earned 9 Income Retained 9 Additional Information Total of Days: 0 Total Income Earned: $0.00 Total Income Retained: $0.00 II did [39; engage in Category or II activities. DI did engage in Category or II activities and total income earned did go; exceed the earning threshold. DI did engage in Category or II activities and total income earned did exceed the earnings threshold (prior approval required). ://dss 1 6_1 7 3/26/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 3 of 3 I certify that have complied with the provisions of the University of California Health Sciences Compensation Plan, the School of Medicine Health Sciences Compensation Plan Implementation Procedures, and my departmental guidelines for the Plan regarding limitations on the retention of earnings, and time spent in Outside Professional Activities. I understand the Dean or his designee may require a copy of my IRS Form 1040, specifically Schedules A and C, and all and 1099s, upon request, as verification of the above information. Note: Information disclosed herein is a public record under the California Public Records Act. Submitted By {HermanowicL Neal Submission Date This signature affirms the form was received and approved. Approved By[ Approval Date Files for Neal Hermanowicz Add File List of Participants Enter Scanned Copy Info Return Form to Faculty 3/26/2019 OPA Of?ce of Academic Affairs I Susan and Henry Samueli College of Health Page 1 of 3 2017-18 Form for Neal Hermanowicz REPORTING PERIOD JULY 1, 2017 ENDING JUNE 30, 2018 Status: Approved on December 3, 2018 In accordance with APM-671, all Compensation Plan participants are required to complete this form and submit for approval no later than November 1, 2018. Earnings threshold is 40% of your component or $40,000 - whichever is greater. The time threshold is 21 days per fiscal year. If you have any questions about the policies governing Outside Professional Activities, please contact your Department CAO. Faculty Name: Hermanowicz, Neal Academic Title: HS Clin Professor Hcomp - 1734 Appointment: School of Medicine Home Department: Neurology 7__l 8 3/26/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 2 of 3 1. Category 0 vI Service Dates 0 I of Days 0 Involved Student Name of Outside Entity 0 Role Nature of Relationship 0 I I Description of Services Activities Provided 3 Income Earned 9 Income Retained 9 Additional Information Total of Days: 0 Total Income Earned: $0.00 Total Income Retained: $0.00 ll did n_ot engage in Category or II activities. DI did engage in Category I or II activities and total income earned did 993 exceed the earning threshold. DI did engage in Category or II activities and total income earned did exceed the earnings threshold (prior approval required). 3/26/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 3 of 3 I certify that I have complied with the provisions of the University of California Health Sciences Compensation Plan, the School of Medicine Health Sciences Compensation Plan Implementation Procedures, and my departmental guidelines for the Plan regarding limitations on the retention of earnings, and time spent in Outside Professional Activities. I understand the Dean or his designee may require a copy of my IRS Form 1040, specifically Schedules A and C, and all W-Zs and 1099s, upon request, as verification of the above information. Note: Information disclosed herein is a public record under the California Public Records Act. Submitted By Hermanowicz, Neal Submission Date This signature affirms the form was received and approved. Approved By [Mozaffan Tahseen Approval Date Files for Neal Hermanowicz Add File List of Participants Return Form to Facultyj SystemAdmin/ 8 3/26/2019 OPA I Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 1 of 2 2014-15 Form for Neal Hermanowicz REPORTING PERIOD JULY 1, 2014 ENDING JUNE 30, 2015 Status: Approved on January 15, 2016 In accordance with APM-025 and APM-670 all Health Sciences Compensation Plan participants are required to complete this form annually. Compiete all parts of the form for the time your appointment was effective during the identified pen'od. income earned in one period but received in the next is reportable in the period earned. Outside Professional Activities, compensated or uncompensated, and regardless of financial interest, are defined as those activities that are within a faculty member?s area of professional, academic expertise and that advance or communicate that expertise through interaction with industry, the community, or the public. For examples of Category I or Category il activities, please click the help button. 8 Earnings threshold is 20% of your or $40,000 - whichever is greater. If you have question, please contact your department administrator. Faculty Name: Hermanowicz, Neal Academic Title: HS Clin Professor Hcomp - 1734 Appointment: School of Medicine Home Department: Neurology 1. Category or ii 9 Name of Outside Entity 6 Service Dates 0 Role 0 of Days 0 Description of Services Provided 0 income Earned 9 ncome Retained 0 No Additional Information TotaE of Days: 0 Tote! Income Earned: $0.00 Total Income Retained: $0.00 Ell did not engage in Category or activities during the reporting period [jTotal income earned did not exceed the earnings threshold certify that I have complied with the provisions of the University of California Health Sciences Compensation Plan, the School of Medicine Health Sciences Compensation Plan lmplementation Procedures, and my departmental guidelines for the Plan regarding limitations on the retention of earnings, and time spent in Outside Professional Activities. I understand the Dean or his designee may require a copy of my Form 1040, specifically Schedules A and C, and all W-Zs and 1099s, upon request, as verification of the above information. Note: information disclosed herein is a public record under the California Public Records Act. Submitted By Hermanowicz, Neal Submission Date 11/18/2015 This signature affirms the form was received and approved. 1 1/12/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 2 of 2 lApproved By [Small, Steven Approval Date Files for Neal Hermanowicz Add FiEe List of Participants Return Form to Facuity 1 5 1 1/12/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 1 of 3 2015-16 Form for Neal Hermanowicz REPORTING PERIOD JULY 1, 2015 JUNE 30, 2016 Status: Submitted on November 12, 2017 In accordance with APM-671, all Compensation Plan participants are required to complete this form and submit for approval no later than October 31, 2016. Earnings threshold is 40% of your component or $40,000 - whichever is greater. The time threshold is 21 days per fiscal year. If you have question, please contact your department administrator. Faculty Name: Hermanowicz, Neal Academic Title: HS Clin Professor Hcomp - 1734 Appointment: School of Medicine Home Department: Neurology 5_1 6 7/3/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 2 of 3 1. Category 1 or II 9 *4 Service Dates 0 of Days 3 Involved Student Name of Outside Entity 9 Role 9 Description of Services Provided 3 Income Earned 9 E: Income Retained 0 Additional Information Total of Days: 0 Total Income Earned: $0.00 Total Income Retained: $0.00 El did n_ot engage in Category I or activities. DI did engage in Category or activities and total income earned did exceed the earning threshold. Ell did engage in Category or activities and total income earned did exceed the earnings threshold (prior approval required). 7/3/2019 OPA Of?ce of Academic Affairs Susan and Henry Samueli College of Health Page 3 of 3 I certify that have complied with the provisions of the University of California Health Sciences Compensation Plan, the School of Medicine Health Sciences Compensation Plan on the retention of earnings, and time spent in Outside Professional Activities. I understand the Dean or his designee may require a copy of my IRS Form 1040, specifically Schedules A and C, and all W-Zs and 1099s, upon request, as verification of the above information. Submitted By Hermanowicz, Neal Submission Date 11/12/2017 Implementation Procedures, and my departmental guidelines for the Plan regarding limitations Note: Information disclosed herein is a public record under the California Public Records Act. This signature affirms the form was received and approved. Approval Date :1 Approved By[ Files for Neal Hermanowicz Add File List of Participants Enter Scanned Copy Info Return Form to Faculty ://dss.hs.uci. 1 5_l 6 7/3/2019