Career Break Request Form
Please read the Career Break Scheme guidelines before completing this form. Copies of the
guidelines are available from intranet.birmingham.ac.uk/hr/leave/development/ or on request
from your HR team.
Name
Payroll number
College/Budget Centre
Job Title
Start date of continuous
employment with the University
Proposed duration of the career
break
Start date
End date
Reason for the career break:
If you intend to undertake work (paid or unpaid) for an organisation other then the
University during your proposed career break, please provide details of the
organisation and the nature of the work to be undertaken:
Please add any other supporting information:
I have read and understood the terms of the Career Break Scheme.
Signed:
Date:
Career Break Scheme
Human Resources (v1.1 September 2011)
1
To be completed by Head of Budget Centre
Please read the Career Break Scheme guidelines before completing this form. Copies of the
guidelines are available from intranet.birmingham.ac.uk/hr/leave/development/ or on request
from your HR team.
Outcome of request
Please tick
one option
I agree to the career break request as set out above.
I have not agreed to a request for a career break and have explained the
reasons for this in writing to the employee.
If the staff member is undertaking paid or unpaid work for another organisation
during their career break, are you satisfied this does not pose a conflict of interest?
If the staff member is employed in an externally funded post, has the funding body
given their agreement to the career break?
Reasons for rejection (where applicable):
Agreed start and end dates of the career break:
Signed:
Date:
Please forward a copy of this form to your HR team
Career Break Scheme
Human Resources (v1.1 September 2011)
2