Special Studies Program:
Application (Form 1)
Instructions for Completing this Form
Submit the completed application form and supporting documents through the Head of School to the
Faculty Office for consideration by the Faculty Special Studies Program Committee.
The application form, with the relevant supporting materials must be received by the Executive Dean by
the advertised closing date
My intention to apply was discussed in my last Employee Development and Review meeting
with my manager/supervisor
I have discussed my intention to apply for Special Studies Program with other members of
my discipline
I have discussed my proposal with my Head of School, including the length, period and
timing of my proposed time on the Special Studies Program, and detailed how my proposed
leave will impact on my commitments and those of the School
I have attached supporting evidence where relevant.
(NB Do not include your curriculum vitae or a list of your publications)
Where applicable
I have attached a written estimate for my travel budget (following discussion with the Travel
Office)
I understand that I will need ethics approval from CSU if my research involve animals or
humans
I understand I may also need ethics approval from other institution(s) if my research involve
animals or humans and that I must obtain it before I start the research
I understand that as this Special Studies Program period contributes to my PhD, I must ask
my supervisor for a statement detailing the relevance of the Special Studies Program
towards the completion of my PhD and include a proposed completion date
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Special Studies Program for Academic Staff
Application Form
1.
Applicant’s details:
Name
Position
School
Faculty
CSU campus
Contact telephone number
E-mail address
Staff number
Discipline Code
Work Function Description
2.
Eligibility
Are you employed in a continuing position?
 Yes
 No
Are you employed on a fixed term appointment of more
than three years?
 Yes
 No
Will you have completed at least 3 years at CSU before
starting SSP?
 Yes
 No
Have you satisfactorily completed your Final Probationary
Review and on-line modules?
 Yes
 No
If applicable, have you completed at least 2 years service
since the completion of your last SSP?
 Yes
 No
Is your performance deemed to be satisfactory by your
Head of School and/or Executive Dean?
 Yes
 No
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3.
Proposed Activities to be Undertaken
The Special Studies Program provides academic staff with an opportunity to undertake
approved professional, scholarly or research activity uninterrupted by teaching and other normal
duties
Indicate what activities will you undertake
professional learning and development
research or creative work
doctoral studies
scholarship of teaching
professional activity, including maintenance and improvement of professional and
vocational knowledge
practise as an artist or performer
experience in the work for which the academic is preparing students
academic leadership and management experience
4.
What is the overall purpose of your Special Studies Program proposal?
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5.
What are the specific objectives of your Special Studies Program proposal (i.e. the outcomes
you hope to achieve)?
6.
How do you intend to achieve these objectives?
7.
What is your proposed schedule?
Dates
Institution
(CSU or host institution)
Special Studies Program: Application Form
Location
(not address)
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Why have you chosen these host institutions/locations?
8.
What professional development benefits do you expect to gain from the Special Studies
Program experience?
9.
How will your proposal assist the Faculty and University in achieving our strategic goals?
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10.
If this application relates to the completion of a PhD, you must include a statement from your
Supervisor, outlining the relevance of the Special Studies Program towards the completion of
the thesis and the expected date for completion and submission of the thesis.
To be completed and signed by the manager/supervisor
11.
Period of the Proposed Special Studies Program period
Start date
Finish date
Total number of weeks
When do you intend to take your annual leave during the year
you are taking SSP?
Are you requesting any other form of leave during the year
you are taking SSP? Please specify the type and duration
12.
External Funding (if applicable)
Please describe any funding being provided by an external
organisation(s) e.g. details of any salary and/or allowances, any
insurance provided by external organisation, e.g. workers’
compensation, public liability, professional indemnity
13.
Travel Grant
Are you applying for a Travel Grant?
Yes
No
Estimate the budget for your proposal. Contact Travel Office for assistance.
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APPLICANT TRAVEL
Description
Travel costs and travel
insurance (if applicable)
Accommodation
Amount
$
$_______ per night/week x ____ nights/weeks
$
Other (specify)
$
TOTAL
$
Any previous Special Studies Program time taken
14.
Dates
15.
Report
submitted
(Y/N)
Outcomes achieved
DECLARATION BY APPLICANT
I understand and acknowledge the conditions that apply to the Special Studies Program, as
outlined in the Policy and Procedure, and agree to abide by them if my application is approved
Signed:
__________________________________________________________
Printed name:
__________________________________________________________
Date:
__________________________________________________________
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COMMENT AND RECOMMENDATION BY HEAD OF SCHOOL/CENTRE
1. Please comment on the extent to which the Special Studies Program proposal supports the
University’s and Faculty’s strategic priorities
2. Please comment on the value of the proposed Special Studies Program activity to the
applicant’s professional development and to the Faculty and University.
3. How will the academic and administrative commitments of the School be satisfactorily
maintained in the staff member’s absence?
4. Other comments.
5. Recommendation
This application is supported
 Yes
 No
The period and timing of this proposal can be accommodated
within the School/Centre operations
 Yes
 No
The applicant has discussed the proposed budget with the Travel
Office and that it is appropriate for the proposal
 Yes
 No
Signed:
_________________________________________________________
Printed name:
_________________________________________________________
Date:
_________________________________________________________
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APPROVAL BY EXECUTIVE DEAN OF FACULTY
To be completed after the meeting of the Faculty Special Studies Program Committee
1. I endorse the School arrangements over the applicant’s absence on Special Studies Program
Yes
No
2.
The proposal relates to the strategic plans of the Faculty and the University
Yes
No
I endorse this application
3.
Yes
No
other (specify)
General comments or conditions of approval
Signed:
__________________________________________________________
Printed name:
__________________________________________________________
Date:
__________________________________________________________
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