Special Studies Program for Academic Staff: Declaration

This declaration is to be completed by the academic following approval of a Special Study Program proposal

Variations to the original Special Study Program proposal can only be made with the approval of the Head of School and Executive Dean. Any changes must be identified in the final documentation and endorsed by the Head of School.

This declaration should be submitted to the Executive Dean via your Head of School / Centre Director up to two (2) months before the start date of the Special Studies Program period.

Evidence Check List

☐ Yes ☐ N/A	I 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/A	I have attached written confirmation from the host institution(s) about the arrangements that have been made in relation to the Special Studies Program.

☐ Yes ☐ N/A	I have attached ethics approval from Charles Sturt University and where appropriate the other institution(s) about the research to be conducted whilst on Special Studies Program which involves animals or humans.

☐ Yes ☐ N/A	I have completed an online leave form for leave I am to take preceding or following the period of Special Studies Program.

☐ Yes ☐ N/A	I have discussed my arrangements with the Travel Office and completed the Special Studies Program Travel Form

Agreement while on the Special Studies Program

Charles Sturt University has approved my proposal to take from Click or tap to enter a date. to Click or tap to enter a date. on the Special Studies Program.

I agree that:

1.	I will stay employed at 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 my employment ends or I am dismissed then I, if required by the Vice-Chancellor, will reimburse the University:

on a pro-rata basis, the equivalent of my salary, the travel grant and five (5) per cent on-costs or

a lesser sum as deemed by the University

Travel Grant Declaration

I Choose an item. Be claiming a travel grant

I hereby declare that the above information is true and correct

Name:

Faculty:

Dates of Special Study Program period Click or tap to enter a date. to Click or tap to enter a date.

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