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Administration
Offices of the Chancellor and Provost
Academic Personnel
Conflict of Commitment and Outside Activities of Faculty Members
Summary
Annual Form
Request Form
UC APM 025
Annual
Instructions
UCD APM 025
Financial Conflict of Interest
Research Conflict of Interest
Leave
Sabbatical
Policy and Instructions
Policies
Instructions
Standing Order 103
of the Regents
State Privacy
Notification
Visual Aids
All Fields
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Current User: TEST, ONE:
ASSOC PROFESSOR - FISCAL YR
ASSOC PROFESSOR - FISCAL YR
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Outside Activity Request
Outside Annual Report
Sabbatic Leave/Leave of Absence
Department:
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Dept of Testing
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Outside Activity Request
Outside Annual Report
Sabbatic Leave/Leave of Absence
Leave/Sabbatic
SAMPLE FORM ONLY - Fiscal Year Professor
FORM WILL NOT WORK/INVALID FORM
SABBATICAL / LEAVE OF ABSENCE FORM
9. Type of Leave
01 Sabbatical Full Salary
02 Sabbatical Partial Salary
03 Sabbatical In Res Full Salary
14 Sabbatical In Res Partial Sal
06 Govt/Public Service
07 Professional Development
08 Personal
11 Military
12 Special Research
13 Admin
18 NSF Benefit Bridge
04 Pregnancy Disability
05 Extended Illness
15 FMLA w/o Pay Pregnancy
15 FMLA w/o Pay Ext Illness
15 FMLA w/o Pay Family Care
16 FMLA with Pay Pregnancy
16 FMLA with Pay Ext Illness
16 FMLA with Pay Family Care
99 Other
10. Pay Period of Leave
Begin Date
Return Date
selected quarters
not contiguous
(mm-dd-yy)
(mm-dd-yy)
11. Academic Year Service
Quarter(s)/Semesters Affected
Summer
Fall
Winter
Spring
6. Address While On Leave
Check box if an international address:
12. Reason for or Specific Purpose of Proposed Leave (for Sabbatical include location while on proposed leave)
13. Other Sources of Income While On Leave (Sabbatical - Indicate nature and amount of all income)
14. Are You a Principal Investigator? Yes
No
Name of Substitute:
15. Has the sponsoring agency approved substitute?
17. Disposition of Work While On Leave
18. UC Compensation While on Leave: No Salary
Full Salary
Other
%
19. Is This an Extension of a Previous Leave? Yes
No
21. If applicant is on a medical school compensation plan
please show proposed salary distribution while on leave.
%
22. If necessary to employ a substitute, what addition to the department budget is required? $
23. If leave is granted, what distribution is to be made of applicant's classes?
24. If in Residence is required what courses and hours per quarter are to be taught by the applicant? See APM 740-8.b for other qualifying activities.
Summer: Course(s):
Hours:
Fall: Course(s):
Hours:
Winter: Course(s):
Hours:
Spring: Course(s):
Hours:
Program Leave Statment:
for application information see
APM 740-94
Indicate in Program Leave Statement arrangements made for continuation and supervision of extramurally sponsored research.
Leave Documentation:
may include itinerary; justification for exception to policy for non-FML leaves with pay over 30 days;
explanation of leave requests without pay; other information applicable to the leave request.
Do not upload FML certification documentation.
Leave without Salary:
please inlcude in the upload a letter explaining absence
Attach document
pdf and MS Word documents only - file size limited to 1 MB
SPECIAL LEAVE OF ABSENCE: If you are on a Special Leave of Absence wihtout pay, your group Life insurance
and Health Plan coverage will terminate unless you make special arrangements for continuance. If you do not
make arrangements for such continuance, and the leave period exceeds two months, you must take action to restore your
coverage upon your return. Re-establishment of coverage is not automatic.
SAMPLE FORM ONLY - Fiscal Year Professor
FORM WILL NOT WORK/INVALID FORM
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Draft
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Standing Order 103 of the Regents
20. I hereby certify that I have read the Standing Order of the Regents and the Regulations of the President governing
the award of sabbatical leaves, and that I shall accept the requested leave, if granted, under the conditions
set forth in these regulations and shall continue my service at the University following said leave for a period of
at least equal to that period of the leave.
SAMPLE FORM ONLY - Fiscal Year Professor
FORM WILL NOT WORK/INVALID FORM
Submit
Draft
