Faculty Assigned Time Request Form

FACULTY ASSIGNED TIME REQUEST FORM

AND REPORT OF WORK ACCOMPLISHED

Name______EmpID ______College______

Last First MI

Dept______Semester______Year______Activity Code______WTU_____

Funding Source Code______Optional: [ ] College funded [ ] Department funded______

Department of Assignment (if not in home college)______

If applicable, check box and attach appropriate documentation:

[ ] VPAA Funds[ ] SCAC Award [ ] TIP Award[ ] EEE Award [ ] New T-T

[ ] Lottery-Funded (Name of Program)______

[ ] Foundation-Funded (Grant Name and #)______

[ ] Interagency Agreement (agency name, project name and #)______

[ ] Chancellor’s Office project/assignment (name)______

DESCRIBE ACTIVITY (indicate nature, objectives and anticipated results):

______Please check: Faculty Member Date

______

Department ChairDate Approved Disapproved

______

HomeCollege DeanDate Initials of Funding Dean Provost and Senior VP for AA Date

======

REPORT ON WORK ACCOMPLISHED WITH ASSIGNED TIME (for Code 22b, attach copy of publication or report made to Director of University Research):

______

Faculty Member Date Department Chair Date Dean Date

LOU/WORDDOCS/Assigned Time Form

INSTRUCTIONS FOR COMPLETING FACULTY ASSIGNED TIME REQUEST FORM

1.The home department of the faculty member receiving assigned time work load is responsible for initiating the Faculty Assigned Time Request Form regardless of location of assignment.

2.The faculty member should complete the form, indicating the following:

NAMELast name, first name, middle initial

SS#Social Security Number

COLLEGEUse only Funding Source Codes below

DEPARTMENTDepartment name

SEMESTERFall or Spring

YEARCalendar year

ACTIVITY CODECode from list below which accurately reflects proposed use of Assigned Time.

Detailed descriptions of each Assigned Time Code are contained in Attachment A of the Assigned Time Guidelines (copy of Assigned Time Guidelines Available for review in each college deans office).

WTUNumber of weighted teaching units of Assigned Time requested.

DEPARTMENT OF ASSIGNMENTWhere proposed activity will take place, if different from faculty members home department. (For example, an ACCT faculty member with Assigned Time in IS should specify the IS Department.)

FUNDING SOURCECollege/Unit which will be charged for assigned time. Use only fund source codes shown below.

DESCRIBE PROPOSALBrief description of proposed activity.

3.The completed from must be certified by the department chair, the college dean and, where necessary, the Provost and Senior Vice-President for Academic Affairs.

FUNDING SOURCE CODESVALID ASSIGNED TIME CODES

CHHSHealth and Human Services11Excess enrollments

CBABusiness Administration12New preparations

CEDEducation14Course or supervision overload

COEEngineering15 Nontraditional instruction

COTAArts16In-Service training for K-12 school personnel

CNSMNatural Sciences and Mathematics17Credit by examination/evaluation

CLALiberal Arts 18Instructional support for graduate students

G&UGGraduate and Undergraduate Studies21Special instructional programs

REIMReimbursed Activities (Foundation grants22aExperimental instructional programs

and Inter-agency agreements)22bInstructionally related research

RSTRRestricted Account (eg. Lottery, AAFD23Instructionally related services

Program)31Advising responsibilities

VPAAVice President for Academic Affairs32Instructionally related committee planning

COChancellor’s Office33Curricular planning

34Accreditation

35Instructionally related facilities planning

41CFA representative