Appendix J
FACULTY EVALUATION STIPEND
NAME: _______________________________________________________________
SS# or Employee ID# _______________________________ Location: ___________
Article 20.4.1: Each semester, faculty members shall be compensated for all but one
of the completed evaluations. Please indicate how this requirement was satisfied.
Name of Faculty member evaluated: _______________________________________
Date evaluation was completed: _______________________________________
Having completed one free evaluation this semester, I wish to be compensated for
evaluating:
Faculty Member: _____________________________________________________
Date evaluation was completed: _________________________________________
Please submit one form for each evaluation; maximum of four paid evaluations per
academic year. Please check the appropriate box:
□ Probationary Evaluation $ 447.00
□ Chair, Probationary Evaluation $ 537.00
□ Peer Evaluation $ 356.00
□ Chair, Peer Evaluation $ 447.00
□ Part-time Evaluation $ 268.00
___________________________ __________________________
Faculty Member Signature Date
________________________________ __________________________
Authorized Dean Name & Signature Division Date
Complete and send one form per evaluation to: Faculty Stipends, Human Resources, District Office
___________________________________ ____________________________________
HR Specialist Date
GL# 11-94-101020-679912-51410 (Funding: M10G)
Form 7121 (Rev 9/00, 12/06, 4/09, 7/13, 10/15, 01/20)
