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 received by 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 Program with 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 leave will 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 (Find some helpful resources on our website (https://staff.csu.edu.au/division/finance/our-services/travel)).

☐ 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 Program towards the completion of my PhD and include a proposed completion date

Applicant’s details

Name:
Position:
School:
Faculty:
Charles Sturt campus
Contact telephone number:
Email address:
Staff number:
Discipline Code:
Work Function Description

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 Charles Sturt University 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

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.

Indicated 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 academic is preparing students

☐ academic leadership and management experience

What is the overall purpose of your Special Studies Program proposal?

< Enter text here >

What are the specific objectives of your Special Studies Program proposal (i.e., the outcomes you hope to achieve)?

< Enter text here >

How do you intend to achieve these objectives?

< Enter text here >

What is your proposed schedule?

Dates	Institution (Charles Sturt or host institution)	Location (not address)

Why have you chosen these host institutions / locations?

< Enter text here >

What professional development benefits do you expect to gain from the Special Studies Program experience?

< Enter text here >

How will your proposal assist the Faculty and University in achieving our strategic goals?

< Enter text here >

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 Program towards 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

< Enter text here >

Period of the Proposed Special Studies Program period

Start date:	Click or tap to enter a date.
Finish date:	Click or tap to enter a 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.

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

Travel Grant

Are you applying for a Travel Grant?	Choose an item.

Estimate the budget for your proposal – (Find some helpful resources on our website (https://staff.csu.edu.au/division/finance/our-services/travel)).

APPLICANT TRAVEL	Description	Amount
Travel costs and travel insurance (if applicable)	$
Accommodation	$ per night / week x $<enter amount> nights / week	$
Other (specify)	$
TOTAL	$

Any previous Special Studies Program time taken?

Dates	Report submitted (yes / no)	Outcomes achieved
Click or tap to enter a date.	Choose an item.
Click or tap to enter a date.	Choose an item.

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

Applicants Signature:	Date: Click or tap to enter a date.

Print name:

COMMENT AND RECOMMENDATION BY HEAD OF SCHOOL / CENTRE

Please comment on the extent to which the Special Studies Program proposal supports the University’s and Faculty’s strategic priorities

< Enter text here >

Please comment on the value of the proposed Special Studies Program activity to the applicant’s professional development and to the Faculty and University.

< Enter text here >

How will the academic and administrative commitments of the School be satisfactorily maintained in the staff member’s absence?

< Enter text here >

Other comments

< Enter text here >

Recommendation

This application is supported	Choose an item.
The period and timing of this proposal can be accommodated within the School / Centre operations	Choose an item.

HOS / Centre Signature:	Date: Click or tap to enter a date.

Print name:

APPROVAL BY EXECUTIVE DEAN OF THE FACULTY

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

I endorse the School arrangements over the applicant’s absence on Special Studies Program.

Choose an item.

The proposal relates to the strategic plans of the Faculty and the University. Choose an item.

I endorse this application. Choose an item.

< other specify here >

General comments or conditions of approval.

< Enter text here >

Executive Dean Signature:	Date: Click or tap to enter a date.

Print name: