Eligibility: Full-time members of the instructional staff, in one of the following titles are eligible to apply: Professor, Associate Professor, Assistant Professor, Instructor, Lecturer, University Professor, Distinguished Professor, Assistant Medical Professor (Basic Sciences), Associate Medical Professor (Basic Sciences), Medical Professor (Basic Sciences), Assistant Medical Professor (Clinical), Associate Medical Professor (Clinical), and Medical Professor (Clinical). - The applicant must have completed not less than one full year of continuous paid full-time service with the University. - An applicant shall be eligible for a subsequent Scholar Incentive Award after six (6) years of creditable service with the University since the completion of the last Scholar Incentive Award. - A Scholar Incentive Award may not be held concurrently with a Fellowship Award. Purpose: Application for a Scholar Incentive Award must be based on bona fide and documented scholarly research. Duration: A Scholar Incentive Award may be made for not less than one semester nor more than one year in duration. HR must verify eligibility for Scholars Incentive Award Application prior to the submission of the application to the academic department. I. Employee Information: Name Title Department Empl ID Date of initial appointment to the University Date of appointment to current title A. Duration and dates of the proposed leave: Indicate dates and purpose of all previous leaves of a semester (or more) for the prior ten (10) years. Attach pages, as necessary Date from Date from Date from Date from Purpose Date from Full year Half year Semester 1 Semester 2 Semester II. Scholar Incentive Award Information THE CITY UNIVERSITY OF NEW YORK Application for Scholar Incentive Award College Date to Date to Date to Date to Date to Purpose Purpose Purpose Purpose Date Signature HR Director Eligibility Verified OHRM-Instructional Staff Academic Leaves - Scholar Incentive Award Form - Revised March 2016 Page 1 of 4 B. Briefly describe the purpose or purposes of the proposed Scholar Incentive Award : (Attach additional pages, as necessary) C. Briefly describe any activities which you have undertaken and/or completed to date in conjunction with the proposed Scholar Incentive Award: (Attach additional pages, as necessary) None D. List the location (s) where the activities associated with the proposed Scholar Incentive Award will occur: (Attach additional pages, as necessary) E. Outside sponsorship and/or service (Attach additional pages, as necessary) i) Will any of the activities associated with the proposed award be sponsored or facilitated by an institution other than The City University of New York? If yes, please name the institution(s) and describe the nature of the sponsorship or facilitation (i.e., laboratory privileges, use of private archives or collections, collaboration with staff, etc. ii) Do you anticipate performing a service for any institution other than The City University of New York during the proposed leave? If yes, please name the institution(s), describe the service which you anticipate performing and state the nature and amount of any compensation which you expect to receive for performing such service: iii) List the nature and amount* of any funding for the proposed award (other than your University salary and personal resources) which you have been awarded or for which you have applied or intend to apply: (* complete details of financial support must be provided) None No Yes No Yes OHRM-Instructional Staff Academic Leaves - Scholar Incentive Award Form - Revised March 2016 Page 2 of 4 Date Contact information during the leave: Address City State Zip Code Country IV. To be completed by the Department Chair Briefly describe how the applicant’s stated purpose for the Scholar Incentive Award is consonant with the mission of the department and college: email Tel.: How does the department intend to cover the applicant’s courses and related responsibilities at the college during the period of the proposed leave: I acknowledge the following: 1. Scholar Incentive Award applications are processed in accordance with the policies of the Board of Trustees of The City University of New York and the Agreement between the Professional Staff Congress and the City University of New York. 2. The information provided is accurate. Should the stated purpose of my leave change, or become unable to be accomplished, even if I have commenced the leave, I shall immediately notify the president in writing. Should the president determine that the purpose of the leave is no longer served, the leave may be terminated, with the assignment of appropriate duties at the college, or other appropriate action. 3. If a Scholar Incentive Award is immediately preceded by full-time continuous service creditable towards tenure or a Certificate of Continuous Employment (CCE) or Fellowship Leave and immediately followed such full-time continuous service, the period of creditable service immediately preceding the Scholar Incentive Award shall be counted in computing the years of service required for granting tenure, CCE or Fellowship Leave. 4. Compensation by the University shall be up to 25% of the individual annual salary rate. The total amount earnable with outside support and the University salary may not exceed 100% of the annual salary rate received without the leave. The amount of compensation from the University may be less than 25% if the amount of any outside fellowship and grant support received would result in earnings above 100% of the salary. 5. Within thirty (30) days following the expiration of my Scholar Incentive Award leave, I shall submit to my department chairperson, a summary, in writing, of my relevant activities during the leave. 6. I acknowledge that my obligation under The City University of New York Intellectual Property Policy to disclose to the University any University-owned intellectual property extends to intellectual property that I create during this leave. 7. I understand that while on leave, employment within or outside of the University is prohibited, unless such involvement is integral to the purpose for which the leave is granted, or there is compelling college justification, and may be engaged in only with the prior approval of the president. III. Attestation of Applicant Signature OHRM-Instructional Staff Academic Leaves - Scholar Incentive Award Form - Revised March 2016 Page 3 of 4 V. Recommendations of Personnel & Budget Committees: (Department, Division, School, etc.) Note: Approval of the Fellowship Award is an endorsement that the work of the department in which the applicant serves can be so arranged as to be carried forward effectively during the period of the leave, and that the work the applicant intends to do is consonant with the principles of the Fellowship Award. Date Title Name Recommend Not recommend Date Title Name Not recommend Recommend Date Title Name Recommend Not recommend Date Title Name Recommend Not recommend Title Date Name Not recommend Recommend Signature Signature Signature VI. Recommendation of the College Personnel & Budget Committee: Signature VII. Recommendation of other College Committees/Offices (as applicable): Signature Signature Date Title Name Not recommend Recommend VIII. Recommendation of other College Committees/Offices (as applicable): Date Signature Name Not recommend Recommend XI. Recommendation of President: Page 4 of 4 Chancellor's University Report Date OHRM-Instructional Staff Academic Leaves - Scholar Incentive Award Form - Revised March 2016