<p> LEAVE OF ABSENCE APPLICATION BRIGHAM YOUNG UNIVERSITY</p><p>Name of Applicant: Date: Employee ID: Current Rank: Continuing Faculty Status: Yes No Department: College: Year of previous leave: </p><p>Type of leave requested: 1If a professional development leave is granted, the faculty member Professional Development Leave 1,2 agrees to remain under contract for full services with Brigham Young University for at least one year immediately following the leave. If the Personal Leave (Limited benefits available) 2 faculty member fails to fulfill this provision, he or she must reimburse the University for gross pay received plus the BYU matching amount Mission President / Temple Presidency 3 for social security and premiums paid by the University for the group insurance program during the leave. Repayment will be in accordance 3 Military Service with an agreement to be made with the University. Deferred payments will bear interest at the rate of eight percent beginning 3 Other : with the date the leave terminates.</p><p>2 Requires Commissioner’s approval Full-time 3 May not require Commissioner’s approval Part-time – indicate fraction of time: </p><p>Length of leave: from to </p><p>Desired financial support from the University to the applicant for professional development leave (do not include salary for regular assignment):</p><p>Salary for period of leave (specify percentage): </p><p>None</p><p>Fringe benefits only</p><p>Other support (attach itemized list)</p><p>Briefly describe your leave proposal:</p><p>I will check with Benefits Services before and after my leave to assure proper continuation or termination of insurance coverage and any other programs in which I am enrolled.</p><p>Signed: ______Date: ______</p><p>Recommendation by Recommendation by</p><p>Department Committee Department Chair Deny leave Deny leave</p><p>Grant leave as requested Grant leave as requested</p><p>Grant leave with modifications listed below: Grant leave with modifications listed below: ______</p><p>______Committee Chair Date Department Chair Date</p><p>Recommendation by Recommendation by</p><p>College Committee Dean Deny leave Deny leave</p><p>Grant leave as requested Grant leave as requested</p><p>Grant leave with modifications listed below: Grant leave with modifications listed below:</p><p>______</p><p>______Committee Chair Date Dean Date</p><p>APPROVED FOR ADMINISTRATION: APPROVED BY COMMISSIONER OF CHURCH EDUCATION: ______</p><p>Date Date</p><p>Instructions to Faculty Member</p><p>Complete the attached sheets to give the following supplementary information: - Provide additional information concerning the proposed program. Indicate specifically how it will relate to and improve your role as a faculty member at BYU. Indicate also if experience gained during the leave will serve as a basis for the development of new instructional or research programs at BYU.</p><p>- List the criteria which you feel should be used to evaluate the success of the leave program.</p><p>- Indicate sources of other funding (in addition to that requested from the University) that will be available to you during the leave.</p><p>- Delineate other items or considerations which you feel are relevant to your proposed leave program.</p><p>- See Benefits Services (D-240 ASB) regarding limitations on benefits.</p><p>Instructions to Department and College Committees</p><p>Attach any expanded comments which have bearing on your recommendations concerning this leave application. If the faculty member does not have continuing faculty status, indicate why the proposed leave is the best use of resources (time and money) at this stage of the academic career. ______</p><p>Following final approval, copies will be made in the AAVP Office and appropriate copies returned to the college for distribution (white- applicant; canary-Dean; pink-Department Chair). The AAVP Office will keep the goldenrod copy and deliver the green copy to Benefits Services. [AAVP Office – 10/29/2010] College Application COLLEGE OF FAMILY, HOME, AND SOCIAL SCIENCES Application for Professional Development Support Funds - Academic Year 2013-14 Please submit all pages to the Dean's Office by December 7, 2012 Name:</p><p>Department:</p><p>Office Address:</p><p>Office Ext:</p><p>Purpose of leave: </p><p>Place where proposed leave will be taken: </p><p>Likely product(s):</p><p>Other external or internal funding applications:</p><p>Amount Requested: Amount Requested: </p><p>Is this leave contingent on external fellowship or funding? If yes, please explain:</p><p>If applicable, please indicate when and where your last professional development leave was taken:</p><p>If application, list below specific results of that leave (publications, curriculum development, retooling, etc.): Describe the plan for your leave. Explain what you are going to do during your leave. Be specific. Be sure to make explicit linkages between your planned activities and the stated objectives of your leave. If you are staying in-residence, describe your plan for “breaking away” from your usual activities and focusing on the activities connected with your leave. If you are planning on going away from campus for your leave, justify your choice of location. If you are working on a specific research project during your leave, describe the project (including its significance and the methods used) and explain how the leave is an important part of the successful completion of the project. </p><p>* * * * * * * * * * * * * * *</p><p>BUDGET (itemize) Amount Requested</p><p>Student Wages </p><p>Supplies</p><p>Travel</p><p>Other</p><p>TOTAL Ranking of Proposal by Department Chair </p><p>No application will be considered without this recommendation and ranking.</p><p>RANK: #______out of ______proposals submitted</p><p>Comments:</p><p>How will this leave benefit the department?</p><p>How will the proposed activities contribute to the development of the faculty member?</p><p>Is this a worthwhile activity for this individual to be engaged in?</p><p>Comments on Proposed Budget:</p><p>Recommendation:</p>