APPLICATION FOR STUDY LEAVE (for staff on Agenda for Change Terms & Conditions) This form is to be completed by staff who wish to attend a study day SECTION ONE TO BE COMPLETED BY APPLICANT PLEASE PRINT CLEARLY – – Full Name: Employee Number: Position: Ward/ Dept: Hospital Site/ Location: Contact Tel No: SECTION TWO STUDY LEAVE DETAILS – Course/ Event Title: Organising Body i.e. University/ Institute/ College: Date of Study Leave: No of Days: Please confirm you have had your Personal Appraisal Development Review (PADR) Meeting and this study leave request is part of your Personal Development Plan (PDP)? Yes: No: Please confirm you have undertaken all of your Mandatory Training requirements? Yes: No: SECTION THREE STUDY LEAVE FUNDING – To be completed by Applicant Authorisation to be completed by Budget Holder Estimated Expenses % Cost Authorisation Comments £ to be Expenses Centre & Signature of Note: where funding is provided by a third party e.g. commercial Expenses claimed Approved Budget Holder sponsor, record here & ensure is completed & authorised. Course/ Event Fee Accommodation Travel & Subs Text Books* Examination Fees* Meals TOTAL SECTION FOUR IF YOU REQUIRE SALARY DEDUCTIONS (PLEASE - COMPLETE, PRINTING CLEARLY) Where and Vale UHB will pay 100% of the fees direct to the College/University; the applicant %age is to recovered via their salary; Employee Number: Contribution Agreed (%age and Total Amount) – to be repaid by the student Amount Per Month: Deduction Commencement Date: Number of Months to be Deducted: (Deductions up to the maximum period of the current academic years' courses) Applicants Signature: Date: Signature: Date: Manager’s SECTION FIVE - AUTHORISATION To be completed by Applicant: I agree to share my learning experience with colleagues and discuss and evaluate the outcome of the learning with my manager Applicants Signature: Date To be completed by Manager/ Head of Department: I do/ do not support this application (delete as appropriate) Comments: Manager/ Head of Dept Signature: Date: To be completed by Senior Manager/ Budget Holder: I do/ do not support this application (delete as appropriate) Comments: Manager/ Head of Dept Signature: Date:
APPLICATION FOR STUDY LEAVE (for staff on Agenda for Change Terms & Conditions) This form is to be completed by staff who wish to attend a study day SECTION ONE – TO BE COMPLETED BY APPLICANT – PLEASE PRINT CLEARLY Full Name: Employee Number: Position: Ward/ Dept: Hospital Site/ Location: Contact Tel No: SECTION TWO – STUDY LEAVE DETAILS Course/ Event Title: Organising Body i.e. University/ Institute/ College: Date of Study Leave: No of Days: Please confirm you have had your Personal Appraisal Development Review (PADR) Meeting and this study leave request is part of your Personal Development Plan (PDP)? Yes: No: Please confirm you have undertaken all of your Mandatory Training requirements? Yes: No: SECTION THREE – STUDY LEAVE FUNDING To be completed by Applicant Authorisation to be completed by Budget Holder Estimated £ Expenses Expenses to be claimed % Expenses Approved Cost Centre Authorisation & Signature of Budget Holder Comments Note: where funding is provided by a third party e.g. commercial sponsor, record here & ensure is completed & authorised. Course/ Event Fee Accommodation Travel & Subs Text Books* Examination Fees* Meals TOTAL SECTION FOUR - IF YOU REQUIRE SALARY DEDUCTIONS (PLEASE COMPLETE, PRINTING CLEARLY) Where and Vale UHB will pay 100% of the fees direct to the College/University; the applicant %age is to recovered via their salary; Employee Number: Contribution Agreed (%age and Total Amount) – to be repaid by the student Amount Per Month: Deduction Commencement Date: Number of Months to be Deducted: (Deductions up to the maximum period of the current academic years' courses) Applicants Signature: Date: Manager’s Signature: Date: SECTION FIVE - AUTHORISATION To be completed by Applicant: I agree to share my learning experience with colleagues and discuss and evaluate the outcome of the learning with my manager Applicants Signature: Date To be completed by Manager/ Head of Department: I do/ do not support this application (delete as appropriate) Comments: Manager/ Head of Dept Signature: Date: To be completed by Senior Manager/ Budget Holder: I do/ do not support this application (delete as appropriate) Comments: Manager/ Head of Dept Signature: Date:
STUDY%20LEAVE%20APPLICATION%20FORM.docx