IMPACT STATEMENT FOR STAFF SABBATICAL LEAVE
(to be completed by immediate supervisor)

The purpose of this form is to provide an accurate estimate of how the requested sabbatical leave will impact on the department, how the department plans to adjust for this leave and how much replacement cost is involved.

           
Applicant’s Name __________________
                         
Department/Division _________________
         
Dates of Requested Leave ______________

Please describe how the department/division plans to complete the applicant’s duties and responsibilities while they are on the sabbatical leave?  If more space is needed, please attach document to this form.







 

 


 


Computation of Replacement Cost


Cost of replacement (use the most recent salary information sheet for part-time salaries; include travel if it will be necessary).


1)    One full time replacement _______________________________                                      


2)    Part-time replacement positions____________________                                              


3)    Total Amount for part-time _________________________                                           


4)    Other (Explain) ________________________________________


If total replacement cost of $0 is the result, please explain.





 
 
 
 
 
 
 
 
 
 
 
 








Comments and Recommendations





Immediate Supervisor   ___ Approved       ___ Denied  (Please check one)

Provide written endorsement of employee’s performance in your approval of this sabbatical leave. If you are denying this application, please explain why.  If more space is needed, please attach document to this form.


Immediate Supervisor’s Signature ____________________________Date_______________


Immediate Supervisor’s Title __________________________________