<p> Payroll/Personnel 1. Campus 2. Employee ID No 3. Date 4. PAF Gen # 10.Sabbatical Type of Leave Leave/Special Leave of Absence UPAY 573 UCR 5. NameSABBATICAL (Last, First, MiddleUPAY Initial) 573 6.LEAVE Personnel OF Program ABSENCE (Complete sections A, C, D) (Complete sections A and B) Academic Staff 7. AddressRegular While onIn LeaveResidence Child Extended Gov/Pub Prof 8.Workers Department Special FMLA FMLA Full Partial Full Partial Bearing Illness Service Dev Personal Comp Furlough MIL Research Admin w/o pay w/pay Othr Salary Salary Salary Salary 04 05 06 07 08 9. Title09 10 11 12 13 15 16 99 (TO CHANGE W-2 OR CHECK ADDRESS – USE FORM UPAY 544) </p><p>11. Pay Period Of Begin Date Return Date 12. Academic Year Service Summer Fall Winter Spring Leave Semester Affected</p><p>A 13. Reason For or Specific Purpose or Proposed Leave (sabbatical: include location while on proposed leave) y</p><p> r a y l m 14. Other sources of income while on leave (sabbatical: indicate nature and amount of all income) n m O u</p><p>S c</p><p> i e 15. Are you a Principal Investigator? 16. Has sponsoring agency approved 17. Note for Sabbatical Leave v m a e</p><p> e Indicate in Program Leave Statement arrangements made for </p><p> d Yes No substitute? Yes No L a continuation and supervision of extramurally sponsored c Name of Substitute A research B 18. Disposition of work while on leave f</p><p> o </p><p> e v</p><p> a 19. U.C. Compensation while on Leave No Full Other % 20. Is this an extension of a previous leave? e</p><p>L Salary Salary e c</p><p> n Yes No e s b A</p><p>C 21. I hereby certify that I have read the Standing Order of the Regents and Employee Signature Date l</p><p> a the Regulation of the President governing the award of sabbatical c i</p><p> t leaves, and that I shall accept the requested leave, if granted, under the a</p><p> b conditions set forth in these regulations and shall continue my service at b</p><p> a the University following said leave for a period of at least equal to the S e</p><p> v period of the leave a e L D 22. If applicant on medical school compensation plan, show 23. If necessary to employ substitute, what addition to </p><p> n proposed salary distribution while on leave % department budget is required? o s</p><p> r e 24. If leave is granted, what distribution is to be made of p r i applicant's classes? a h</p><p>C 25. If in residence is required, what courses and hours per quarter to be taught by applicant?</p><p> t</p><p> n Hours Hours Hours e</p><p> m Quarter Quarter Quarter t r</p><p> a Courses Courses Courses p e Names Names Names D e</p><p> v Does applicant have full yes no Does applicant have full yes no Does applicant have full yes no a e</p><p>L responsibility for courses? responsibility for courses? responsibility for courses? </p><p> l l a a c</p><p> v Remarks i t o r a Prepared by Phone Number Employee p b p b</p><p> a A S</p><p> r Dept Chair Date Dean Date Personnel Date o</p><p>F Provost Date Chancellor Date</p><p>Standing Order 103 Special Provisions Concerning Officers, Faculty Members, and Employees of the University</p><p>2103.4 Sabbatical Leaves. Professors, Associate Professors, Assistant Professors, persons of equivalent rank, and Cooperative Extension Specialists,</p><p>CC: Dean, Dept, Academic Personnel, Employee, Accounting Retn: Payroll – 5 yrs / APO – 5 yrs / Other Copies – 0-5 yrs after sep Advisors, and Agronomists shall be entitled, upon approval of the A sabbatical leave of absence in residence at the President, to the privilege of a sabbatical leave of absence from University may be granted, provided that, in addition to a program regular scheduled duties, following a prescribed period of service of research, writing, or equivalent activity at one of the University in the University as academic appointees with the rank of campuses, such person will teach at a University campus one Instructor or higher, or equivalent rank, or with such other titles as class, meeting regularly at least three hours each week, or will the Board may approve. perform an equivalent amount of instructional service in a course Sabbatical leaves are granted to enable recipients to be or courses regarded as essential to the program of that campus. engaged in intensive programs of research and/or study, thus to An appointee on sabbatical leave of absence in residence shall be become more effective teachers and scholars and to enhance their freed from all other teaching obligations and from all committee services to the University. and administrative work. A regular sabbatical leave of absence at less than full A sabbatical leave of absence may be taken at varying salary may receive an additional salary: (1) by appointment to the percentages of regular salary in accordance with regulations Miller Institute for Basic Research in Science, the Institute for established by the President. Creative Arts, or the Humanities Institute, or such organized A sabbatical leave of absence shall be granted and research programs as the Board may approve for this purpose; or accepted only with the understanding that the recipient, following (2) for limited service on a research or teaching project in a leave of absence, will continue service at the University for a foreign university or for work on a research project, provided such period at least equal to the period of the leave, unless specifically research or teaching project is administered by the University with approved by the President. funds from government or private grant or contract, and provided further that the terms of such grant or contract specifically 1As amended 1-21-83. authorize such usage of such funds and when the work to be performed by the recipient will promote the purpose of the leave.</p><p>Privacy Notification State</p><p>The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply information:</p><p>The principal purpose for requesting the information on this form is to process paychecks. University policy authorizes maintenance of this information.</p><p>Furnishing all information requested on this form is mandatory – failure to provide such information will delay or may even prevent completion of the action for which the form is being filled out. Information furnished on this form may be used by various University departments for payroll and personnel administration, and will be transmitted to the Federal and State governments as required by law.</p><p>Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Information on applicable policies and agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices.</p><p>The officials responsible for maintaining the information contained on the form: Office of the President and Campus Academic and Staff Personnel Managers or Campus Accounting Offices.</p><p>CC: Dean, Dept, Academic Personnel, Employee, Accounting Retn: Payroll – 5 yrs / APO – 5 yrs / Other Copies – 0-5 yrs after sep</p>