Faculty of Medical Sciences
Academic Leaver Checklist
School/Institute:
Colleagues on academic contracts (clinical and non-clinical) are requested to complete an Academic Leaver
Checklist as soon as they are aware that they will be leaving the University, and within four weeks of giving formal
notice to the University of their intention to resign.
It is expected that any finances, equipment, samples or other university property will not be removed from the
University. It is further expected that such items will be left in good order, with a named individual to undertake
any ongoing management that is required.
Where there is a case for such items to be removed from the University, the request will be considered initially by
the Head of Academic Unit, and if a case is considered to be viable, the request will be escalated to the Pro-ViceChancellor’s office for consideration at Faculty level. Items should not be removed from University premises until
that approval has been formally granted.
Section 1. HR
What is the name of the leaver?
Job Title :
What is the proposed leave date?
Has a letter of resignation, including final working date, been sent to HR?
YES
NO
Are there any other staff directly affected by the resignation?
YES
NO
If answer is YES, please indicate:
Name(s)
What, if any, arrangements have been made for these
staff?
Section 2. UG Teaching Commitments
i. Does the staff member have UG teaching commitments which will require cover?
YES
NO
If answer is YES, please indicate:
Course(s)
Module(s)
Version 2, approved FSG 23.03.2016
What, if any, arrangements have been made for these
ongoing commitments (include staff names where
appropriate)?
Where another
member of staff
has agreed to
cover, please
ask them to
initial to confirm
their
acceptance.
ii. Does the staff member have UG tutor commitments which will require cover?
YES
NO
If answer is YES, please indicate:
Tutee Name(s)
Course(s)
What, if any, arrangements have been made for ongoing tutor
cover for these tutees (include staff names where
appropriate)?
Where another
member of staff
has agreed to
cover, please
ask them to
initial to confirm
their
acceptance.
Section 3. PG Teaching Commitments
i. Does the staff member have PG teaching commitments which will require cover?
YES
NO
If answer is YES, please indicate:
Course(s)
Module(s)
What, if any, arrangements have been made for the ongoing
commitments (include staff names where appropriate)?
Where another
member of staff
has agreed to
cover, please
ask them to
initial to confirm
their
acceptance.
Section 4. PGR Supervision Commitments
i. Does the staff member supervise any PGR students?
YES
NO
If answer is YES, please indicate :
Name(s)
Area of Research
Version 2, approved FSG 23.03.2016
What, if any, arrangements have been made for the ongoing
supervision of these PGR students (include staff names where
appropriate)?
Where another
member of staff
has agreed to
cover, please
ask them to
initial to confirm
their
acceptance.
Section 5. Administrative Duties
iii. Does the staff member have key administrative roles which will require cover?
YES
NO
If answer is YES, please indicate:
Duty
What, if any, arrangements have been made for these
commitments (include staff names where appropriate)?
Where another
member of staff has
agreed to cover, please
ask them to initial here
to confirm acceptance.
Head of
Academic Unit
to initial to
confirm
agreement
Section 6. External Funding Commitments
i. Does the staff member have any external funding contracts (Research/Consultancy
etc.)?
YES
NO
If answer is YES, please indicate:
Project Number(s)
Funder(s)
Have arrangements been made with the funder to:
Head of
Academic Unit
to initial to
confirm
agreement
a) Transfer funds to new institution
b) Transfer PI
Y
Y
N
N
a) Transfer funds to new institution
b) Transfer PI
Y
Y
N
N
a) Transfer funds to new institution
b) Transfer PI
Y
Y
N
N
a) Transfer funds to new institution
b) Transfer PI
Y
Y
N
N
ii. If answer is YES to transfer funds to new institution, please indicate the name of the institution and contact:
iii. If answer is YES to transfer PI, please indicate the name of the new PI(s) for each contract :
iv. Have all contractual arrangements with the funder been executed (eg. Final Report)
Version 2, approved FSG 23.03.2016
YES
NO
Section 7. Internal Funding Commitments
Does the staff member have any internal funding accounts (Cost Centres etc.)?
YES
NO
If answer is YES, please indicate:
Account
Number(s)
Have arrangements been made with the Head of Academic
Unit to:
a) Transfer funds to PI
Y
b) Transfer to another internal source Y
N
N
a) Transfer funds to PI
Y
b) Transfer to another internal source Y
N
N
a) Transfer funds to PI
Y
b) Transfer to another internal source Y
N
N
a) Transfer funds to PI
Y
b) Transfer to another internal source Y
N
N
If YES to previous
question, please indicate
the name of the new
PI(s) or recipient for
each account, or the
account number:
Head of
Academic
Unit to
initial to
confirm
agreement
Section 8. Equipment
Does the staff member have any equipment which was purchased on grants or via University
funds?
YES
NO
If answer is YES, please indicate:
Item(s)
Current location(s)
Who will assume responsibility and what will the management
arrangements be for this equipment going forward?
Head of
Academic Unit
to initial to
confirm
agreement
Section 9. Samples, slides, data or other items
i. Does the staff member have any samples, animals, slides, data or other items including
chemical or radiation which need to be handed over before leaving?
Please refer to the section above for any equipment emitting ionising radiation, details of
which must be provided.
YES
NO
Genetically modified organisms class 1-3
YES
NO
Pathogens, Hazard Group (HG)2, HG3, Schedule 5 and SAPO
YES
NO
PHO Schedules 1-6 Licenses
YES
NO
Chemical Weapons
YES
NO
Radioactive Materials (open and closed sources)
YES
NO
Lasers
YES
NO
ii. In particular, does the staff member have any of the following materials:
Version 2, approved FSG 23.03.2016
If answer is YES, to (i) or (ii) above, please indicate:
Item(s)
Current
location(s)
Who will assume
responsibility for their
ongoing storage and
documentation?
What will the local
arrangements be for the
ongoing management of
the above?
Please asked
any named
individuals
assuming
responsibility
to initial here
for their
agreement
Head of
Academic
Unit to
initial to
confirm
agreeme
nt
*Additional
authorisati
on (see
below)
* Additional Authorisation:

Details of any samples considered under the Human Tissue Act must be forwarded to Professor Andy Hall, Associate Dean
for Bioresources for review, Professor Hall will initial the form.

Details of items identified in subsection (ii) must be forwarded to the Occupational Health and Safety Service
(http://www.ncl.ac.uk/ohss/about/contact.htm) who will initial the form.
Section 10. Intellectual Property
Does the staff member have any vested interest in Intellectual Property Rights (e.g.
Patents, Registered Designs):
YES
NO
If the answer is yes, please indicate:
i. IPR title(s) and brief description:
ii. Which Business Development Manager in the Faculty is dealing with this?
iii. Have arrangements been made to transfer IPR to new institution?
YES
NO
iv. If the answer YES to transfer IPR to new institution, please indicate the name of the institution and contact(s):
Has the staff member invented any technologies and/or processes which have not
yet been disclosed to the University and could potentially qualify for registered
(patents, trademarks, registered designs) or unregistered (software, designs,
checklists, protocols, questionnaires, toolkits, guidelines, database rights) IP?
If YES, give details below:
Version 2, approved FSG 23.03.2016
YES
NO
Section 11. Clinical Staff
Does the staff member have any clinical commitments?
YES
NO
If answer is YES, please confirm that you have notified the appropriate NHS organisation(s)
YES
NO
Section 12. Authorisation
We confirm that satisfactory arrangements are in place to cover all commitments as indicated above:
SIGNED :
__________________________________
STAFF MEMBER
DATE :
___________________
SIGNED :
____________________________________
HEAD OF SCHOOL/DIRECTOR OF INSTITUTE
DATE :
___________________
Please send copy of form to :
Ms Katharine Rogers
Director of Faculty Operations
Faculty Office
Faculty of Medical Sciences
Newcastle University
Medical School
Framlington Place
NE2 4HH
Reviewed by FSG:
YES
NO
Date:
Approved on behalf of FSG
__________________________________
SIGNATURE
___________________________________
PRINT NAME
Version 2, approved FSG 23.03.2016