/ Special Studies Program: Application (Form 1)

Instructions for Completing this Form

Submit the completed application form and supporting documents through the Head of School to the Faculty Office for consideration by the Faculty Special Studies Program Committee.

The application form, with the relevant supporting materials must be receivedby the Executive Dean by the advertised closing date

My intention to apply was discussed in my last Employee Development and Review meeting with my manager/supervisor

I have discussed my intention to apply for Special Studies Programwith other members of my discipline

I have discussed my proposal with my Head of School, including the length, period and timing of my proposed time on the Special Studies Program, and detailed how my proposed leavewill impact on my commitments and those of the School

I have attached supporting evidence where relevant.

(NB Do not include your curriculum vitae or a list of your publications)

Where applicable

I have attached a written estimate for my travel budget (following discussion with the Travel Office)

I understand that I will need ethics approval from CSU if my research involve animals or humans

I understand I may also need ethics approval from other institution(s) if my research involve animals or humans and that I must obtain it before I start the research

I understand that as this Special Studies Program period contributes to my PhD, I must ask my supervisor for a statement detailing the relevance of the Special Studies Programtowards the completion of my PhD and include a proposed completion date

Special Studies Program for Academic Staff

Application Form

  1. Applicant’s details:

Name
Position
School
Faculty
CSU campus
Contact telephone number
E-mail address
Staff number
Discipline Code
Work Function Description
  1. Eligibility

Are you employed in a continuing position? /  Yes  No
Are you employed on a fixed term appointment of more than three years? /  Yes  No
Will you have completed at least 3 years at CSU before starting SSP? /  Yes  No
Have you satisfactorily completed your Final Probationary Review and on-line modules? /  Yes  No
If applicable, have you completed at least 3 years service since the completion of your last SSP? /  Yes  No
Is your performance deemed to be satisfactory by your Head of School and/or Executive Dean? /  Yes  No
  1. Proposed Activities to be Undertaken

The Special Studies Program provides academic staff with an opportunity to undertake approved professional, scholarly or research activity uninterrupted by teaching and other normal duties
Indicate what activities will you undertake
professional learning and development
research or creative work
doctoral studies
scholarship of teaching
professional activity, including maintenance and improvement of professional and vocational knowledge
practise as an artist or performer
experience in the work for which the academicis preparing students
academic leadership and management experience
  1. What is the overall purpose of your Special Studies Program proposal?
  1. What are the specific objectives of your Special Studies Programproposal(i.e. the outcomes you hope to achieve)?
  1. How do you intend to achieve these objectives?
  1. What is your proposed schedule?

Dates / Institution
(CSU or host institution) / Location
(not address)

Why have you chosen these host institutions/locations?

  1. What professional development benefits do you expect to gain from the Special Studies Program experience?
  1. How will your proposal assist the Faculty and University in achieving our strategic goals?
  1. If this application relates to the completion of a PhD, you must include a statement from your Supervisor, outlining the relevance of the Special Studies Programtowards the completion of the thesis and the expected date for completion and submission of the thesis.

To be completed and signed by the manager/supervisor

  1. Period of the Proposed Special Studies Program period

Start date
Finish date
Total number of weeks
When do you intend to take your annual leave during the year you are taking SSP?
Are you requesting any other form of leave during the year you are taking SSP? Please specify the type and duration
  1. External Funding(if applicable)

Please describe any funding being provided by an external organisation(s)e.g. details of any salary and/or allowances, any insurance provided by external organisation, e.g. workers’ compensation, public liability, professional indemnity
  1. Travel Grant

Are you applying for a Travel Grant? Yes No

Estimate the budget for your proposal. Contact Travel Office for assistance.

APPLICANT TRAVEL / Description / Amount
Travel costs and travel insurance (if applicable) / $
Accommodation / $______per night/week x ____ nights/weeks / $
Other (specify) / $
TOTAL / $
  1. Any previous Special Studies Program time taken

Dates / Report submitted (Y/N) / Outcomes achieved
  1. Declaration by applicanT

I understand and acknowledge the conditions that apply to the Special Studies Program, as outlined in the Policy and Procedure, and agree to abide by them if my application is approved

Signed:______

Printed name:______

Date: ______

Commentand recommendation by Head of School/CENTRE

  1. Please comment on the extent to which the Special Studies Programproposal supports the University’s and Faculty’s strategic priorities
  1. Please comment on the value of the proposed Special Studies Programactivity to the applicant’s professional development and to the Faculty and University.
  1. How will the academic and administrative commitments of the School be satisfactorily maintained in the staff member’s absence?
  1. Other comments.
  1. Recommendation

This application is supported /  Yes  No
The period and timing of this proposal can be accommodated within the School/Centre operations /  Yes  No
The applicant has discussed the proposed budget with the Travel Office and that it is appropriate for the proposal /  Yes  No

Signed:______

Printed name:______

Date:______

APPROVAL BY EXECUTIVE DEAN OF FACULTY

To be completed after the meeting of the Faculty Special Studies Program Committee

  1. I endorse the School arrangements over the applicant’s absence on Special Studies Program Yes No
  1. The proposal relates to the strategic plans of the Faculty and the University

Yes No

  1. I endorse this application

Yes No other (specify)

General comments or conditions of approval

Signed:______

Printed name:______

Date:______

Special Studies Program: Application FormPage 1