ANNUAL HEALTH SCIENCES CUMPENEATIDN PLAN
REFDRTIHG FDRM FDR CATEGORY I die II UUTSIDE ACTIVITIES

Re or1in Period: Fiscal 'r'earJu

I 31] 1013

In accordance vvith ti?l'l all Compensation Plan Participants are required to complete and submit this form by September r23 it] I it

 

 

 

 

 

Name (Print)? seine Title Department A -
Hit-i? Siamese Hft?HaES'ttL
Type of It of Name of Entity Rule Description of Services Provided i rnings For each activity:
activity: Days he maximum annual outside professional
CategoryI amings threshold is season or d??ia oi? the Plan
II

articipant?s academic year base salary [Settle El],
whichever is greater. This includes cash and non-

 

 

 

 

 

cash compensation.
is? is:
{in Law Fir?Res MEarceLr if 37:953

 

 

 

 

 

Tia-tea" 1: pays- 

 

 

 

 

 

Tom! income earned ii

 

 

I did not engage in Category I or II activities during the reporting period-
1 engaged in Categoqy i activities and obtained prior approval {pleam attach approval I?crrn}.

I eaweded the income threshold

1: or 40% ofthc Plan Participant?s ?scal year base salary {Scale ii}

I exceeded the time threshold {maximum of 43 days per ?scal year}

Ell certify that I have complied with the provisions ol'lhe University oFCalifornia 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 on ?reside Ptofessional Activities-

 

. Faculty Sagan-1:5

 

Dale

waif, M44. ass?awe

 

Lite Chair's signature a?in'ns that the Form was received and reviewed.
attentive actions should be implemented ifthc timt: 

were eaceecbd without approval or ii" there were unapproved Category I
activities.

if
Depart Ch irSi Dale

 

 

 

 

 

 

Pill:
3

Information disclosed herein is a public record under the California Public Records Act