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Rev 9/10/2015
Campus:
LSU
Date
Submitted:
_________________
Campus Split: % LSU:
% Ag PBRC HSCNO:
_______
SABBATICAL LEAVE REQUEST
Name: LSU ID:
Department: College:
Present Rank/Title: Last Appointment Date:
[Academic & Administrative, if applicable]
Appointment Status
Pay Basis
Tenured
Term
AY
FY
Graduate Faculty Status
Member
Associate
None
Dates of Leave
Pay Status Requested
From: ________________________
To: ________________________
Full Pay
Half Pay
Previous Leaves Granted
Type
Date
Pay Status
Purpose
Education
Institution
Degree
Date Awarded (mm/yyyy)
Professional Experience [include experience acquired at any of the LSU campuses]
Institution
Rank
Period of Appointment
-
-
-
-
-
Years of Service
In LSU System
to effective
leave date:
__________
Candidate: ___
I.) EVALUATION BY DEPARTMENT CHAIR / HEAD
I. A.) How will this leave enhance the ability of the applicant to meet his/her responsibilities
within the LSU System?
I.B.) What is your overall evaluation of this request?
Recommended
Recommended with conditions
(state conditions in Section I.C)
Do not recommend
(state reasons in Section I.C)
I.C.) Comments (from Section I.B.)
I.D.) How do you rate this
request among all other
requests from your department?
I.E.) Applicants current
salary:
I.F.) Applicants current
teaching credit hours:
out of
(Numeric Rank) (Numeric Rank)
$
Fall Semester
Spring Semester
Summer Sessions
I.G.) Is replacement teaching needed?
I.H.) Is a replacement needed for other
departmental duties?
No Yes
No Yes
Rank:
Rank:
Teaching Load:
Teaching Load:
Cost: $
Cost: $
Department Chair/Head Signature: __ Date: ____
2
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Candidate: ____
II.) EVALUATION BY DEAN / DIRECTOR
II.A.)
What is your overall evaluation of this request?
Recommended
Recommended with Conditions
(State conditions in Section II.C)
Do not recommend
(give reasons in Section II.C)
II.B.)
Do you agree with the evaluation and replacement needs of the Department
Chair/Head?
Yes
No
(If no, explain in Section II.C)
II.C.) Comments (from Section II.A. and Section II.B.)
II.D.)
How do you rate this request among all other requests from your department?
________________ out of ________________
(Numerical Rank) (Numerical Rank)
Dean/Director Signature: Date: _
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Candidate: ______________________________________________________________
SIGNATURE PAGE
DEPARTMENT ACTION
*Attach required recommendation

Recommended
Not recommended
Chair Signature: Date:
COLLEGE ACTION
*Attach required recommendation

Recommended
Not recommended
Dean Signature: Date:
SPLIT APPOINTMENT CAMPUS ACTION 
Ag

Pennington

HSCNO

Recommended
Not recommended
Authorized Signature: Date:
CAMPUS ACTION

Recommended
Not recommended
Executive Vice President & Provost Signature: Date:
PRESIDENTIAL ACTION

Recommended
Not recommended
President Signature: Date:
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