Request for Sabbatical Leave Application Form

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Request for Sabbatical Leave
Eligible faculty shall use this form, together with an attached proposal and other materials, to request a sabbatical leave.
Submit the completed form and attachments to Faculty Affairs by the announced deadline. If you have questions
regarding use of this form, call Faculty Affairs at 664-2192 (CRS 877-735-2929 TTY). Please keep a signed copy for your
records.
TO BE COMPELTED BY APPLICANT
Name:
Employee ID:
Dept. Name:
Date of Hire
School:
Have you taken a Sabbatical or DIP Leave?
No
Yes
If Yes, Date of last Sabbatical or DIP Leave from (date):
to (date):
Leave of 2 semesters either as 2 consecutive semesters OR as two semesters over 2 consecutive years.
Leave Request
Instructional Faculty or others in Academic Year Assignments:
One (1) semester at full pay for the (semester)
(year)
Two (2) semesters at one-half pay for the
/
Academic Year
Two (2) semesters at one-half pay for the (semester)
Librarians in 12-Month Assignments:
Four (4) months at full pay beginning (month, year)
(year)
,
Eight (8) months at one-half pay beginning (month, year)
and (semester)
and ending (month, year)
,
(year)
,
and ending (month, year)
,
Title or short description of proposed work/project to be completed during leave:
Required Attachments
Pursuant to Article 27 of the collective bargaining agreement, I will indemnify the University against loss in the event of failure, through
fault of my own, to fulfill this agreement in the following manner:
I have attached a promissory note for this purpose, OR
I request that the President waive a promissory note or bond and I have attached a list of assets, the value of which is in excess of the
salary to be paid to me during leave, as evidence of my capacity to indemnify the State of California against loss if I fail to fulfill the
agreement, OR
I have attached a bond of sufficient value for this purpose.
AND
I have attached to this application the following materials:
A statement of purpose of the leave and a clear and detailed description of the proposed project, including the CSU resources, if
any, necessary to carry it out and the potential benefit for the University.
A copy of your prior sabbatical/DIP report (if no report attached, explain reason here: __________________________________________)
A current curriculum vitae supplemented by information on the nature of my past service to the University including teaching;
committee assignments; artistic, professional, and scholarly activities; creative and scholarly publications; grant proposals;
curriculum development; and other activities which support the applicant's proposal for a sabbatical leave.
Signature of Applicant
Submit form and attachments to Faculty Affairs by September 15.
Date:
APPLICANT’S RESPONSIBILITY ENDS HERE, SUBMIT TO FACULTY AFFAIRS BY SEPTEMBER 15
TO BE COMPLETED BY DEPARTMENT CHAIR
Recommended:  Yes  No
Signature: ________________________________________________________ Date: ______________
Forward to Dean/Director with a one page recommendation
TO BE COMPLETED BY DEAN/DIRECTOR
Recommended:  Yes  No
Signature: ________________________________________________________ Date: ______________
Forward to Faculty Affairs with a one page recommendation
TO BE COMPLETED BY CHAIR OF URTP
Recommended:  Yes  No
Signature: ________________________________________________________ Date: ______________
Forward to Faculty Affairs with the ranked list
URTP Recommendation received in Faculty Affairs:
Initials________
Date:______________
Faculty Affairs 8/2015
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