REPORT OF ACTIVITIES DURING LEAVE OF ABSENCE WITHOUT PAY Name of Applicant Department Period of Leave Fall (year) Other Check One: Personal Leave (see Section 676.2) Check One: Full-time Leave Part-time (% of Leave) College Spring (year) Academic Year (year)
Professional Leave (see Section 676.1)
Statement of activities during leave of absence: (Indicate how the leave was utilized, what goals were pursued, and how these efforts will benefit the University. Use additional sheets if necessary.)
Signature of Faculty Member Date (Forward to Associate Vice President for Faculty Affairs for granting of credits) RECOMMENDATION OF THE Credit toward: S.S.I. Credit toward Tenure Credit toward Sabbatical Date
Signature of Associate Vice President, Faculty Affairs
For Faculty Affairs Use: Distribute one copy to:
Human Resources Services
Dean
Department Chair
Applicant
Faculty Affairs
n:forms:lwop_report (Revised 8/03)