The University of Texas Health Science Center at San Antonio
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The University of Texas Health Science Center at San Antonio Supplemental Payment to Faculty
Faculty Name:______Badge #:______
Department:______Title:______Job Code:______
Charge Salary to: Project: ______Fund: ______Amount $______
Title of Program or Project:______
Date(s) and Time(s) of Service (Attach supporting documentation): ______
______
Date(s) Type of Service Flat Rate Rate Per Hour Payment (rate x hours) x
x
x
Total Payment
Additional Services Required For: □ Staffing shortages or vacancies □ Patient volume or unanticipated event □ Other (list reason) ______
______
Certification of Performance: I certify that the above services were rendered.
Certified by: ______Faculty Signature Date
Requested by:______Approved by:______Division Chief Date Chair or Director of Employee Date
Approved by:______Approved by:______Office of the Dean Date President or EVP/CFO Date