I. Instruction and Advising
A. Scheduled Teaching (Please verify the following scheduled teaching activities and make
any necessary changes on the copy.) By signing this form, I certify that sufficient course
Materials are posted on Blackboard to continue my course online in the event of an
Course Name Course No. & Section Credit Hours Meeting Time
Value of non-teaching time $ ________ (nine month salary ÷ 27 x teaching hours fewer than nine)
B. Unscheduled Teaching (Please list such activities as: supervising student teachers;
advising thesis, dissertation, special problems courses, etc.; indicate approximate
number of hours weekly.) Hrs. _____
C. Please indicate scheduled conference hours in the space below. Hrs. _____
II. Research and Scholarly Activities (during this term).
A. Funded Research Projects (list each project) Hrs_____
B. Unfunded Research Activities Hrs. _____
C. Other Scholarly Activities Hrs. _____
III. Service (Professional Role)
(See Appendix C of Tenure and Promotion Guidelines) Hrs. _____
A. To the Unit/College/University
B. To the profession
C. To the public
Total Hours Per Week
Excluding Scheduled Teaching __________
__________________________ ______________________ ________________________
Faculty Member Department Head Dean
9/09 - AA
(To be completed at the end of each quarter; for complete evaluation, future reports may be necessary.)
Accomplishments of non-teaching activity (documentation may be attached or requested):
Summary of Unit and College benefits (strategic plan objectives, self-appraisal goals accomplished, unit
mission, etc.)
Accomplishments to be realized at a later date:
Signature _______________________________ Date _____________________________
______ Accepted
______ Additional report required by (date) _________________________
Unit Head ________________________________ Date _____________________________
9/09 AA