Fillable Admin-sabbatical-request-form-final-06-30-17 Leave of Absence Form3

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Admin-sabbatical-request-form-final-06-30-17 Leave of Absence Form3

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ADMINISTRATIVE SABBATICAL LEAVE REQUEST FORM
SUM FALL WTR SPR
SABBATICAL OUTCOMES
DEPARTMENT
TITLE
COCC ID
#
NAME (Last, First, Middle Initial) DATE PREPARED
Please read instructions prior to completing the request and submit all information for consideration in one packet. You must
include a letter of support from 1) immediate supervisor and 2) appropriate Presidential Advisory Team (PAT) member identifying
budget requests to support the Sabbatical, how the employee job assignment will be covered, and if another employee will work
out of class to complete some or all of the work assignment.
DEADLINE: The completed request must be submitted by the 4th Monday of November, 4:30 p.m. to the President of COCC.
The President will notify applicants by January 31 of the year prior to the sabbatical request if the proposal has presidential
approval.
Give a brief statement of how this sabbatical support COCC's Strategic Plan themes and objectives?
PERIOD OF
LEAVE
ACADEMIC YEAR SERVICES
QUARTERS AFFECTED
BEGIN DATE RETURN DATE
Give a brief statement of how this sabbatical contributes to your professional expertise for professional growth and/or meets
the goals identified on your Annual Evlauation.
Sabbatical Abstract
Abstract, including top three completeion goals:
YEARS OF
CONTINUOUS
SERVICE
PRIOR SABBATICALS
TAKEN?
IS THIS AN EXTENSION OF A PREVIOUS LEAVE?
m Yes
m No
REVISED RIO 1/20/17
Human Resources Review
Review Date:
A
pproved
Not Approved
REQUIRED APPROVALS AND ROUTING
EMPLOYEE SIGNATURE DATE
OTHER SOURCES OF INCOME AND AMOUNT WHILE ON
SABBATICAL:
Proposed Plan of Activities
Please note how your activities are linked to the sabbatical outcomes noted above:
In accepting a Sabbatical Leave of Absence, I agree to furnish a written
report summarizing the project accomplishments and to adhere to all terms
and conditions set forth in Section 8 of the Exempt and Confidential
Supervisory Handbook, including repayment. Upon approval, employee
must complete the MOA.
Supervisor Signature
Approved
DATE
Not Approved
DEPARTMENTAL REVIEW
Review Date:
Budget Review
Eligibility Met
Personnel Cost $
Pr
esidential Review
Presidential Signature:
DATE
Recompensable Items (travel, lodging, books, materials, meals, and tuition) up to $1200 for 1.0 FTE, prorated for less than
1.0 FTE but more than .5 FTE (please attach original receipts) If you need more room, attach page to back of Approval.:
Item Cost Approved
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Completed 8 February 2020

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