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