Faculty of Medical Sciences
Academic Leaver Checklist
School/Institute:
Colleagues on academic contracts (clinical and non-clinical) are requested to complete an Academic Leaver Checklist as soon as they are aware that they will be leaving the University, and within four weeks of giving formal notice to the University of their intention to resign.
It is expected that any finances, equipment, samples or other university property will not be removed from the University. It is further expected that such items will be left in good order, with a named individual to undertake any ongoing management that is required.
Where there is a case for such items to be removed from the University, the request will be considered initially by the Head of Academic Unit, and if a case is considered to be viable, the request will be escalated to the Pro-Vice-Chancellor’s office for consideration at Faculty level. Items should not be removed from University premises until that approval has been formally granted.
Section 1. HRWhat isthe name of the leaver?
Job Title :
What is the proposed leave date?
Has a letter of resignation, including final working date, been sent to HR? / YES NO
Are there any other staff directly affected by the resignation? / YES NO
If answer is YES, please indicate:
Name(s) / What, if any, arrangements have been made for these staff?
Section 2. UG Teaching Commitments
- Does the staff member have UG teaching commitments which will require cover?
If answer is YES, please indicate:
Course(s) / Module(s) / What, if any, arrangements have been made for these ongoing commitments (include staff names where appropriate)? / Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance.
- Does the staff member have UG tutor commitments which will require cover?
If answer is YES, please indicate:
Tutee Name(s) / Course(s) / What, if any, arrangements have been made for ongoing tutor cover for these tutees (include staff names where appropriate)? / Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance.
Section 3. PG Teaching Commitments
- Does the staff member have PG teaching commitments which will require cover?
If answer is YES, please indicate:
Course(s) / Module(s) / What, if any, arrangements have been made for the ongoing commitments (include staff names where appropriate)? / Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance.
Section 4. PGR Supervision Commitments
- Does the staff member supervise any PGR students?
If answer is YES, please indicate :
Name(s) / Area of Research / What, if any, arrangements have been made for the ongoing supervision of these PGR students (include staff names where appropriate)? / Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance.
Section 5. Administrative Duties
- Does the staff member have key administrative roles which will require cover?
If answer is YES, please indicate:
Duty / What, if any, arrangements have been made for these commitments (include staff names where appropriate)? / Where another member of staff has agreed to cover, please ask them to initial here to confirm acceptance. / Head of Academic Unit to initial to confirm agreement
Section 6. External Funding Commitments
- Does the staff member have any external funding contracts (Research/Consultancy etc.)?
If answer is YES, please indicate:
Project Number(s) / Funder(s) / Have arrangements been made with the funder to: / Head of Academic Unit to initial to confirm agreement
a)Transfer funds to new institutionY N
b)Transfer PIY N
a)Transfer funds to new institutionY N
b)Transfer PIY N
a)Transfer funds to new institutionY N
b)Transfer PIY N
a)Transfer funds to new institutionY N
b)Transfer PIY N
ii. If answer is YES to transfer funds to new institution, please indicate the name of the institution and contact:
iii. If answer is YES to transfer PI, please indicate the name of the new PI(s) for each contract :
iv.Have all contractual arrangements with the funder been executed (eg. Final Report) / YES NO
Section 7. Internal Funding Commitments
Does the staff member have any internal funding accounts (Cost Centres etc.)? / YES NO
If answer is YES, please indicate:
Account Number(s) / Have arrangements been made with the Head of Academic Unit to: / If YES to previous question, please indicate the name of the new PI(s) or recipient for each account, or the account number: / Head of Academic Unit to initial to confirm agreement
a)Transfer funds to PIY N
b)Transfer to another internal source Y N
a)Transfer funds to PIY N
b)Transfer to another internal source Y N
a)Transfer funds to PIY N
b)Transfer to another internal source Y N
a)Transfer funds to PIY N
b)Transfer to another internal source Y N
Section 8. Equipment
Does the staff member have any equipment which was purchased on grants or via University funds? / YES NO
If answer is YES, please indicate:
Item(s) / Current location(s) / Who will assume responsibility and what will the management arrangements be for this equipment going forward? / Head of Academic Unit to initial to confirm agreement
Section 9. Samples, slides, data or other items
- Does the staff member have any samples, animals, slides, data or other items including chemical or radiation which need to be handed over before leaving?
- In particular, does the staff member have any of the following materials:
Genetically modified organisms class 1-3 / YES NO
Pathogens, Hazard Group (HG)2, HG3, Schedule 5 and SAPO / YES NO
PHO Schedules 1-6 Licenses / YES NO
Chemical Weapons / YES NO
Radioactive Materials (open and closed sources) / YES NO
Lasers / YES NO
If answer is YES, to (i) or (ii) above, please indicate:
Item(s) / Current location(s) / Who will assume responsibility for their ongoing storage and documentation? / What will the local arrangements be for the ongoing management of the above? / Please asked any named individuals assuming responsibility to initial here for their agreement / Head of Academic Unit to initial to confirm agreement / *Additional authorisation (see below)
* Additional Authorisation:
- Details of any samples considered under the Human Tissue Act must be forwarded to Professor Andy Hall, Associate Dean for Bioresources for review, Professor Hall will initial the form.
- Details of items identified in subsection (ii) must be forwarded to the Occupational Health and Safety Service ( who will initial the form.
Section 10. Intellectual Property
i. Does the staff member have any vested interest in Intellectual Property Rights (e.g. Patents, Registered Designs): / YES NO
If the answer is yes, please indicate:
a. IPR title(s) and brief description:
b. Which Business Development Manager in the Faculty is dealing with this?
c. Have arrangements been made to transfer IPR to new institution? / YES NO
d. If the answer YES to transfer IPR to new institution, please indicate the name of the institution and contact(s):
ii. Has the staff member invented any technologies and/or processes which have not yet been disclosed to the University and could potentially qualify for registered (patents, trademarks, registered designs) or unregistered (software, designs, checklists, protocols, questionnaires, toolkits, guidelines, database rights) IP? / YES NO
If YES, give details below:
Section 11. Clinical Staff
Does the staff member have any clinical commitments? / YES NO
If answer is YES, please confirm that you have notified the appropriate NHS organisation(s) / YES NO
Section 12. Authorisation
We confirm that satisfactory arrangements are in place to cover all commitments as indicated above:
SIGNED : / ______
STAFF MEMBER / DATE : / ______
SIGNED : / ______
HEAD OF SCHOOL/DIRECTOR OF INSTITUTE / DATE : / ______
Please send copy of form to :
Ms Katharine Rogers
Director of Faculty Operations
Faculty Office
Faculty of Medical Sciences
Newcastle University
Medical School
Framlington Place
NE2 4HH
Reviewed by FSG: YES NO
Date: / Approved on behalf of FSG ______
SIGNATURE
______
PRINT NAME
Version 2, approved FSG 23.03.2016