Form 112 - Request For Exclusion Of Time From Probationary Period

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REQUEST FOR EXCLUSION OF SERVICE TIME FROM TENURE PROBATIONARY PERIOD
(FOR REASONS OTHER THAN CHILDBIRTH OR ADOPTION)
Name _________________________________ Employee ID ________________________________________
TIU ________________________________ College _____________________ Campus ____________________
Date of appointment at tenure-track faculty rank _________________ Date of request _____________________
If not yet completed, are you requesting moving your Fourth Year Review? _____________
Number of prior exclusions, if any:
_____ Childbirth/Adoption
_____ Other
Faculty Member's signature _______________________________________________ Date ______________
* * * * *
This form is forwarded only if approval is recommended at each successive level (see below). In the event of a negative
recommendation, the faculty member should be informed promptly of the denial of the request. The provost makes the
final decision. A copy of the approved form will be returned to the dean.
Faculty request submitted before April 1 of the year in which the mandatory promotion and tenure review is presently
scheduled (See Faculty Rule3335-6-03 (D) (2).):
Yes
No
APPROVAL LEVELS WITH SIGNATURES
DATE
Regional campus dean/director (if applicable) ____________________________________________________________
TIU Head _________________________________________________________________________________________
College Dean ______________________________________________________________________________________
Provost ___________________________________________________________________________________________
The following 4 documents must be submitted with this form.
____ Applicant's detailed statement of reasons for request
____ Letter from TIU head (for salaried joint appointments, include letter from head of other unit)
____ Report of TIU promotion and tenure committee's review of request
____ Faculty member's current CV
To be filled out by the Office of Academic Affairs
Presently Scheduled
Approved
Fourth Year Review, if not yet completed
20__/__
20__/__
Mandatory promotion & tenure review
20__/__
20__/__
Office of Academic Affairs Exclusion of Service Form, Rev. 07/13
Form 112

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