Special Studies Program for Academic Staff: Declaration
This declaration is to be completed by theacademic following approvalof a Special Study Program proposal
Variations to theoriginal Special Study Programproposal can only be made with the approval of the Head of School andExecutive Dean. Any changes must be identified in the final documentation and endorsed by the Head of School.
This declaration should be submitted to theExecutive Dean via your Head of School/Centre Director up totwo (2) months before the start date of the Special Studies Program period.
Evidence Check List
Yes N/AI have attached evidence to show that I have met the conditions set by the Executive Dean on approval of my Special Studies Program proposal.
Yes N/AI have attached written confirmation from the host institution(s) about the arrangements that have been made in relation to the Special StudiesProgram.
Yes N/AI have attached ethics approval from CSU and where appropriate the other institution(s) about the research to be conducted whilst on Special StudiesProgram which involves animals or humans.
Yes N/AI have completed an online leave form for leave I am to take preceding or following the period of Special StudiesProgram.
Yes N/AI have discussed my arrangements with the Travel Office and completed the Special StudiesProgram Travel Form
Agreement while on the Special Studies Program
Charles Sturt University has approved my proposal to take from …/…/… to …/…/… on the Special StudiesProgram.
I agree that:
1.I willstay employedat Charles Sturt University for a period equal to the time I am on the Special Studies Program (excluding all leave except sick leave)
2.If myemploymentends or I am dismissed then I, if required by the Vice-Chancellor,will reimburse the University:
(a)on a pro-rata basis, the equivalent of my salary, the travel grant and five (5) per cent on-costsor
(b)a lesser sum asdeemed by the University
Travel Grant Declaration
I will /will not be claiming a travel grant
I hereby declare that the above information is true and correct
Name ......
Faculty …………………………………………….
Dates of Special Study Program period .…./..…/……. to ..…/….../……...
Signature ......
Date: ......