STUDY LEAVE REPORT
This form shall be completed electronically by the staff member and submitted to the Secretary, Faculty
Study Leave Committee within 60 calendar days of return to normal duties.
PART A
Confidential Information Regarding Leave Period and Financial Accountability
Given Name
Family Name
Title
Faculty/Division
School/Section
Present Position
Academic Level
1.
Dates of Leave Taken
Type of Leave
From
To
Number of
Weeks/Days
From
To
Weeks/Days
Study Leave (within Tasmania)
Study Leave (outside Tasmania)
Annual Leave
Long Service Leave
Leave Without Pay
Other
TOTAL
2.
Variations in additional income and/or financial assistance as estimated at Part A Section 3
in Notification to Commence Leave and Study Leave Allowance form
Amount
3.
Purpose or Nature
of Income or Assistance
Source
Expenditure Details for Study Leave Program
Details
Air Fare
Cost
Living
Expenses
TOTAL Expenditure
Other
Total
$
4. Variations from final approved Study Leave program
Provide a detailed description of variations to the final approved Study Leave program, justification for
variations and anticipated or achieved outcomes.
5.
Travel Tickets are attached for the following relevant journeys: (please attach a copy of
relevant travel tickets)
Details of Journey
Date: …………………
Cost of Ticket
Signature: ………………………………………………
Staff Member
UNIVERSITY OF TASMANIA
STUDY LEAVE REPORT
PART B
Summary Report for Public Information Purposes
Given Name
Family Name
Title
Faculty/Division
School/Section
Present Position
University Postal Address
Telephone
Fax
Email
Dates of Study Leave program
Total Length of Study Leave program
From ..…/..…/..…
………. Weeks
To ..…/..…/..…
……. Days
Summary of Study Leave Program (This summary, of 250 words maximum, is to be written in the third
person and should focus on the main objectives of the Study Leave Program)
Date: …………………
Signature: ………………………………………………
UNIVERSITY OF TASMANIA
STUDY LEAVE REPORT
PART C
Report to Faculty and University Committee
Given Name
Family Name
Title
Faculty/Division
School/Section
Present Position
Dates of Study Leave (within Tasmania)
From ..…/..…/..…
To ..…/..…/..…
Dates of Study Leave (outside Tasmania)
From ..…/..…/..…
To ..…/..…/..…
1.
2.
Approved Itinerary
Institution/School
Country
City
eg University of Melbourne
eg Australia
eg Melbourne
Date from
Date to
Objectives and Measurable Outcomes identified in approved Study Leave program.
List the objectives and outcomes (eg publications, submissions, papers, courses, exhibitions, concerts) in
250 words maximum.
3.
Achievement of the objectives, including those anticipated over the next 12 months
List the achievements, including anticipated dates of publication/application in 150 words maximum.
4.
Details of Study Leave activities
List the activities (eg lectures, seminars, papers, conferences, research studies, concerts) in approximately
150-300 words.
5.
Benefits gained for the University and personally
List the benefits with reference to strategic plans and approved Study Leave objectives in 150 words
maximum.
6.
Other relevant matters
Date: …………………
Signature: ………………………………………………
UNIVERSITY OF TASMANIA
STUDY LEAVE REPORT
PART D
Head of School Comments
1.
The extent to which the objectives of the program have been achieved
Rank on a scale 1 (none achieved) to 5 (all achieved). If appropriate, comment on particular aspects of
(non)achievement and/or problems encountered.
2.
Identify and/or confirm benefits gained for the University
Date: ……………………
Signature: …………………………………………………
Head of School
UNIVERSITY OF TASMANIA
STUDY LEAVE REPORT
PART E
Evaluation by Faculty Study Leave Committee
1.
Overall evaluation of Study Leave Report
Please  as appropriate:
Unsatisfactory
Satisfactory
CRITERIA
Successful completion of study leave program as approved.
Record of productivity or considered potential from study leave program
relevant to scholarship and research as evidenced by the quality and
number of publications and/or, where applicable, other creative
achievement.
Record of productivity, or considered potential from study leave program
relevant to teaching and teaching development.
The academic appropriateness of the study leave program which
enhanced the performance of the academic beyond normal academic
activities and with specific comment on methodology and measurable
outcomes.
Consistency with School and Faculty Strategic plan.
Support of the Head of School.
2.
Additional Comments if Required
Date: ………………
Signature: ……………………………………..………
Chair, Faculty Study Leave Committee
UNIVERSITY OF TASMANIA
STUDY LEAVE REPORT
PART F
Endorsement by Dean
Dean’s comments regarding variations to Study Leave program and financial accountability
1.
(a)
Any concerns regarding changes to the Study Leave program (if appropriate):
(b)
Action, if appropriate, to be taken regarding possible overpayment of Study Leave Allowance due to
increased external financial assistance obtained during leave or due to default in returning to full duties as
known at this time:
2.
Comments on Study Leave program taking into consideration the evaluation by Faculty
Study Leave Committee
Date: …………………………
Signature: …………………………………………………
Dean
Note:
Following completion of Parts A - F, the Dean shall arrange for:
1. The staff member and Head of School to be provided with a copy of Parts D - F of the Study Leave
Report; and
2. The original of the Study Leave Report (Parts A - F) and related documentation to be forwarded to the
Secretary, Staff Development Committee no later than 31 August.