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 __________________
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 __________________________________