Faculty Single Semester Leave
1. Complete Faculty Single Semester Leave Form and submit to department head.
2. If request is recommended by department head/chair, submit form to college screening committee.
3. Forward request, with priority ranking, from college screening committee to the Dean/Vice Chancellor.
4. If request is approved, provide signed copies to:
Dean/Vice Chancellor Department Employee Benefits
5. Enter approved leave information into PeopleSoft prior to the beginning of the single semester leave.
more information, see Board of Regents Policy: Employee Development, Education, and Training at
loyee_Develop_Educ_Training.pdf and the University Administrative
Policy: Faculty Development Leaves at http://policy.umn.edu/hr/facleaves.
Name Empl ID
Rank or Title Job Code
DeptID Entity College
Start Date of Requested Leave End Date of Requested Leave
Annual Full-Time Base Salary Basic Term of Appointment 9 to 10 mo. term paid over 12?
Yes No
Appointment Type
Clinical Scholar
Multiple-Year Contract
Annually Renewable
Yearly Appt – Med School
Project to be Conducted During Le
ave - attach additional information if necessary
Title of Project: Institution or Location where project would be conducted:
Nature and significance of project in terms of scientific, scholarly, or artistic value, and/or practical application:
Present state of knowledge or accomplishment on subject – General status:
Present state of knowledge or accomplishment on subject – Your background or activities in this area:
Description of research design or project plan (include specific information on approach to the project, methods to be used, potential
results, and why the Single Semester Leave will facilitate this activity):
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Route this form to:
See Routing
Instructions Below
U Wide Form
UM 21
Rev: 06/16
Applicant Information
List up to five of your recent personal publications or accomplishments (or equivalents) which may be related to the project:
Plans for publication or other outcome as a result of this project:
Dates of previous leaves in the past 10 years
Single Quarter/Semester: Sabbatical: Summer Faculty Research
Appointment :
Dates of anticipated future leave requests, if known:
I will su
bmit a report on my semester leave to the department head/chair and college dean/campus vice chancellor within th
onths of returning.
In the event that I do not return to the University of Minnesota for a period at least equal to the period of the leave, I agree to th
llowing terms except in the case a waiver is grante
1. I will reim
burse the University of Minnesota for any salary paid during the semester leave, and
2. I will reimburse the University of Minnesota for its share of the retirement contributions and insurance premiums paid during
the sem
ester leave.
I will
not accept any other salary or compensation for services while on se
mester leave.
Requested in accordance with Board of Regents Policy: Employee Development, Education, and Training and the University
Administrative Policy:
ulty Development Leaves.
Signature Date
Prepared By Date
Campus Address Phone Number
Recommended – (Provision for the applicant’s work will be made within the funds of the department.)
Department Head Signature
College Screening Committee
Rank or priority given this application: Total number of applications from this college:
Signed Date
Dean/Vice Chancellor Signature Date
The University of Minnesota is an equal opportunity educator & employer.
© 2009 by the Regents of the University of Minnesota.
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