Data Collection Form - Sta
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1STA Data Collection Form
First Name:
Last Name:
Banner ID:
Faculty
Dept or Faculty:
100
Contract
Reason for Request under Section A or B please check the appropriate category:
Medical
Academic
Other &
Description:
Administrative
Section A: Unavailable Time Slot(s)
Column I = Instructors: Mark unavailable time slot(s) with an X
Column AT = Academic Timetabler: Mark appropriate level of categorization – 1,2,3 or N/A (not approved)*
Monday
Tuesday
Wednesday
Thursday
Friday
Column
AT
A
AT
AT
AT
I
I
I
I
I
T
8:30am–9:30am
9:30am–10:30am
10:30am–11:30am
11:30am–12:30am
12:30pm–1:30pm
1:30pm–2:30pm
2:30pm-3:30pm
3:30pm-4:30pm
4:30pm-5:30pm
6:00pm-7:00pm
7:00pm-8:00pm
8:00pm-9:00pm
9:00pm-10:00pm
Category levels must be assigned by the Academic Timetabler
Category 1 (Legislative Requirements)
Category 2 (Reported Circumstances)
Category 3 (May Accommodate)
Carleton Human Rights Policy
A medical condition not covered by
Category 3 requests will be considered
Category 1 Family/personal issues of a
and will be accommodated if possible
serious nature, other official academic
responsibilities
Section B.1: Location Restrictions/Requirements; or
Section B.2: Modification of General Parameters
Level of Categorization AT to
Special Arrangement Details
indicate level: 1, 2, 3 or
NA
Instructor to complete
(not approved)
Signature of Instructor:
Date:
Signature of Chair (1):
Date:
Signature of Chair (2):
Date:
NOTE: Cross-Appointed Faculty require signatures of both chairs
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Parent category: Business