??ࡱ?>?? ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????c ???bjbj???? 4D?Kb?Kb? ???????^ ^ ????????????8&$J??I??????666???????$??? R??66666?????H?@&&&6F?????&6?&&&?????YK???????|F&~<I&? ?d? &? ?&X66&66666??&666I6666????????????????????????????????????????????????????????????????????? 666666666^ B ?: Modified Instructional Duties (MID) Application ChecklistName: ______________________________ Title: ___________________________________Department: __________________________ College: ________________________________Eligibility Criteria* - All items in this section must be checked to forward application (check, ()Is the applicant a full-time faculty member?Is the applicant the primary caregiver of a child?, or, Is the applicant the primary caregiver of an immediate family or household member who is ill or disabled?Is the applicant on a regular appointment (i.e., not term)? Does the applicant have instructional duties, either on or off-campus?Is the MID workload agreeable to both the applicant and the department head?Is this the applicants first or second MID request?Is the request within 12 months of the qualifying event?Is a signed agreement in place for the applicant to resume regular duties for at least 8-months after the period of modified instructional duties?Is the period of time being requested for the MID allowable?* Note: Faculty are ineligible if they have been denied tenure or received Notice of Non-ReappointmentDepartmental Planning InformationSpecify the period being requested: Fall semester [ ] Spring semester [ ] ____ months (must be four or less) Has the applicant requested a delay in the tenure clock?[ ] Yes [ ] No [ ] N.A.Will the period of MID be shared with another K-State faculty member who is a co-equal caregiver?Has the applicant requested concurrent FMLA? If so, for what portion of the period of MID? _____ FTEApplication Process, please check, (Was the MID request submitted at least 5 months in advance? If not, is the statement explaining the reason for exception attached?Is there a statement justifying the need for MID?Is there a statement of caregiver status, primary or co-equal?Is there a proposal describing requested modifications, including description of the duties that will be performed during the MID period? Department/Unit Head ApprovalDH Initials __________________________________ is eligible to apply for MID and this application meets policy criteriaThis proposal is in the best interest of the unit?s and the school/college?s missionsApproval of this MID request will not disrupt or cause undue burden to the unit/department/programSIGNATURE: DATE: _____________________________________________ _____________________________Print Name:Approved by:__________________________________________ ____________________ , Dean/Vice President DATE___________________________________________ ____________________ , Provost DATE:???   % E F H I     Y Z [ \ ] ^ ? ? ? ? ? ? ) * d e ? ? 5 6 7 8 : @ ? ? ? ? ? ? ? ? ? ? ? DE?????????ֻ???త???జ????జ????????????Ȋజh"]Wh? ?5?CJh`?CJaJh? ?CJaJh?h? ?:?CJaJh?h? ?CJaJ j??h?h? ?5?CJh? ?5?CJh`?5?CJh?h? ?5?CJh?h? ?CJh?h? ?5?>*CJh?"h? ?5?CJ6;<????H I v w ? ????????m???xkd$$If?l??r'r' ? t?? ?????0???????r'??????????4?4? la?lp? ????yt`? $Ifgd? ?$a$gd? ?$a$gd? ? ?    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(k ???(0No List j???j PY? Table Grid7:V?0??????4@4 3;0Header?H?$.??. 3;0 Header Char4 @"4 3;0Footer?H?$.??1. 3;0 Footer CharP?BP ?0 Balloon TextCJOJQJaJmHsHtHN?/??QN ?0Balloon Text CharCJOJQJ^JaJB' ??aB ?0Comment ReferenceCJaJHrH ?0 Comment TextCJaJmHsHtHB?/???B ?0Comment Text CharCJaJ@jqr@ ?0Comment Subject5?\?N?/???N ?0Comment Subject Char5CJ\aJPK!????[Content_Types].xml???N?0E?H???-J??@%?ǎǢ|?ș$?ز?U??L?TB? l,?3??;?r??Ø??J??B+$?G]??7O٭V???c:???E3v@?P?~??D?s? |??w?v? ? D???? E??? !? ] ? * ? 7 ? ? ?C?f2t?:????  ?T? # ? ????@?????????H ??0?( ? ????0?( ? ??B ?S ???? ??? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ??8:????E F ? ? ? ? ? ? ?o?"(?<_t?&'&?)%5+?Wh9?D?Q?? ?`?y?? ? ?@? ? ? ? ? ?@??UnknownSUSANA L. VALDOVINOS????????????G??* ??Times New Roman5??Symbol3.? ?.?Cx? ?Arial;??Wingdings7.??*?{$? ?Calibri5.? ?.?[`?)?TahomaA????$B?Cambria Math"????h??z???z?ԣ??? ??? !?8hx???r4? ? ?3?Q???HP ?? $P??????????????????????PY2!xx????M ???Svaldovi Sandra Brase?? ?????Oh??+'??0l?????????   @ L Xdpx???? SvaldoviNormalSandra Brase3Microsoft Office Word@?@l???@wR??@J:v???? GԐ????VT$m?! ZH?  1.????@Times New Roman--- 2 >H0    0'??'??????@Times New Roman--- 2 ?H0    0'??'??????@Times New Roman--- 2 O?0   ????@Times New Roman--------- a2 `?90 Modified Instructional Duties (MID) Application Checklist    --- 2 `^0  ????@Times New Roman---?- @ !?tb?????-? --- 2 p?0    A2 ?H$0 Name: ______________________________   2 ?R0   2 ?h0  0 J2 ??*0 Title: ___________________________________  2 ??0    2 ?H0    D2 ?H&0 Department: __________________________   2 ?W0   2 ?h0  0 I2 ??)0 College: ________________________________  2 ??0    2 ?H0    ???????- @ !???H- ???????H????@Wingdings--------- ???????- @ !???O- ????--- )2 ?OH???Eligibility Criteria   2 ??H???* 2 ??H???  2 ??H???- 2 ??H???  2 ??H???All  ,2 ??H???items in this section   2 ?qH???must be  2 ??H???checked 2 ??H???  :2 ??H???to forward application (check,   --- 2 ??H????--- 2 ??H???) 2 ??H???  '???- @ !??G-- @ !??G-- @ !???H- ???- @ !???-- @ !???- ???- @ !??G- ???- @ !???- ????]?H????@Times New Roman--- .2 ?OH?]?Is the applicant a full 2 ??H?]?- )2 ??H?]?time faculty member?    2 ?6H?]?  '?????^--- 2 ?d^???  '??????--- _2 ??8????Is the applicant the primary caregiver of a child?, or,   2 ??????   ^2 ??7????Is the applicant the primary caregiver of an immediate    ------ 12 ??????family or household membe    12 ?#????r who is ill or disabled? --- 2 ??????  '??????--- 2 ??????  '??- @ !??G-- @ !??H- ???- @ !??\-- @ !?)?]- ???- @ !???-- @ !?6??- ???- @ !???-- @ !?*??- ???- @ !???- ???- @ !??G- ???- @ !??\- ???- @ !???- ???- @ !???- ???- @ !???- ????]?H--- U2 ?O1H?]?Is the applicant on a regular appointment (i.e.,    2 ?O H?]?not term)?   2 ??H?]?  '?????^--- 2 ?d^???  '??- @ !??G-- @ !??H- ???- @ !??\-- @ !?)?]- ???- @ !???- ???- @ !???- ???- @ !???- ???- @ !??G- ???- @ !??\- ???- @ !???- ???- @ !???- ???- @ !???- ???]?H--- P2 O.H?]Does the applicant have instructional duties,   #2 OH?]either on or off 2 ?H?]- 2 ?H?]campus?  2 ?H?]  '????^--- 2 r^??  '?????--- 2 ????Is the M  2 ????I L2 ?+???D workload agreeable to both the applicant    /2 ????and the department head?  2 ???  '?????--- 2 ????  '??- @ !??G-- @ !??H- ???- @ !??\-- @ !?)?]- ???- @ !???-- @ !?6??- ???- @ !???-- @ !?*??- ???- @ !???- ???- @ !??G- ???- @ !??\- ???- @ !???- ???- @ !???- ???- @ !???- ???7]H--- 2 %O H]7Is this the 2 %?H]7  :2 %?H]7applicants first or second MID     2 4OH]7request? 2 4}H]7  '??7?^--- 2 %r^?7  '??7??--- V2 %?2??7Is the request within 12 months of the qualifying     2 4???7event? 2 4???7  '??7??--- 2 %???7  '??- @ !?G-- @ !?H- ???- @ !?\-- @ !?)]- ???- @ !??-- @ !?6?- ???- @ !??-- @ !?*?- ???- @ !??- ???- @ !?G- ???- @ !?\- ???- @ !??- ???- @ !??- ???- @ !??- ???f]8H--- U2 DO1H8]fIs a signed agreement in place for the applicant    F2 SO'H8]fto resume regular duties for at least 8  2 SH8]f- 2 SH8]fmonths   V2 cO2H8]fafter the period of modified instructional duties?  2 cSH8]f  '??f?8^--- 2 Er^8?f  '??f?8?--- 2 D??8?fIs the  L2 D?+?8?fperiod of time being requested for the MID     f?8?'??'?? 2 S? ?8?fallowable?  2 S??8?f  f?8?'??'??'??f?8?--- 2 D??8?f  '??- @ !?7G-- @ !?7H- ???- @ !?7\-- @ !?)7]- ???- @ !?7?-- @ !?67?- ???- @ !?7?-- @ !?*7?- ???- @ !?7?- ???- @ !?.8G- ???- @ !?.8\- ???- @ !?.8?- ???- @ !?.8?- ???- @ !?.8?- ??? ???????- @ !??gH- ???? v?gH????@Times New Roman- - - ---- - - ---- - - --- ???????- @ !??gO- ????  2 s?Hg?v*  2 s?Hg?vN - - -  2 s?Hg?vOTE--- 2 s?Hg?v:- - -  2 s?Hg?v --- q2 s?DHg?vFaculty are ineligible if they have been denied tenure or received N  2 s Hg?votice of  2 sCHg?vN  2 sLHg?von 2 sZHg?v- 2 s^Hg?vR 2 sf Hg?veappointment  2 s?Hg?v  v?gH'??'??'??- @ !?fG-- @ !?fH- ???- @ !?f\-- @ !?)f]- ???- @ !?f?-- @ !?6f?- ???- @ !?f?-- @ !?*f?- ???- @ !?f?- ???- @ !?gG- ???- @ !?vG-- @ !?vG-- @ !??vH- ???- @ !?g?- ???- @ !?v?-- @ !?v?- ???--- 2 ?H0    ???????- @ !???H- ???? ???H--- ???????- @ !???O- ????  =2 ?O!H???Departmental Planning Information     2 ?2H???  '??- @ !??G-- @ !??G-- @ !???H- ???- @ !???-- @ !???- ???- @ !??G- ???- @ !???- ????\?H--- @2 ?O#H?\?Specify the period being requested: 2 ?H?\?  ?\?H'??'?? 2 ?OH?\?  (2 ?`H?\?Fall semester [ ]  2 ??H?\?  +2 ??H?\?Spring semester [ ]  2 ?<H?\?  ?\?H'??'?? 2 ?OH?\?  @2 ?`#H?\?____ months (must be four or less)    2 ?H?\?  ????@Times New Roman- - -  2 ?OH?\?  '?????]--- 2 ?r]???  '??????--- _2 ??8????Has the applicant requested a delay in the tenure clock?  2 ??????  ------ R2 ??/????[ ] Yes [ ] No [ ] N.A.   --- 2 ?Q????  '??????--- 2 ??????  '??- @ !??G-- @ !??H- ???- @ !??\-- @ !?)?]- ???- @ !???-- @ !?7??- ???- @ !???-- @ !?)??- ???- @ !???- ???- @ !?2?G- ???- @ !?2?\- ???- @ !?2??- ???- @ !?2??- ???- @ !?2??- ????\?H--- P2 ?O.H?\?Will the period of MID be shared with another      2 ?OH?\?K  2 ?XH?\?- 82 ?\H?\?State faculty member who is a     2 ?H?\?co 2 ?H?\?- 2 ?H?\?equal   2 ?O H?\?caregiver? 2 ??H?\?  '?????]--- 2 ?r]???  '??????--- O2 ??-????Has the applicant requested concurrent FMLA?    2 ??????   2 ??????  O2 ??-????If so, for what portion of the period of MID?    2 ??????   2 ??????  2 ?? ????_____ FTE 2 ??????  - - -  2 ??????  '??????--- 2 ??????  '??- @ !??G-- @ !??H- ???- @ !??\-- @ !?)?]- ???- @ !???-- @ !?7??- ???- @ !???-- @ !?)??- ???- @ !???- ???- @ !?2?G- ???- @ !??G-- @ !??G-- @ !??H- ???- @ !?2?\- ???- @ !??\-- @ !?)?]- ???- @ !?2??- ???- @ !???-- @ !?7??- ???- @ !?2??- ???- @ !???-- @ !?)??- ???- @ !?2??- ???- @ !???-- @ !???- ???--- 2 ?0    ???????- @ !??H- ???? #?H ???????- @ !??O- ???? --- (2 OH?#Application Process   #2 ?H?#, please check, --- 2 *H?#? --- 2 6H?#  '??- @ !?G-- @ !?G-- @ !??H- ???- @ !??-- @ !??- ???- @ !?G- ???- @ !??- ???Q]#H--- I2 /O)H#]QWas the MID request submitted at least 5      52 ?OH#]Qmonths in advance? If not,  2 ??H#]Qis the statem  2 ?&H#]Qent   "2 NOH#]Qexplaining the  )2 N?H#]Qreason for exception 2 N H#]Q  2 N H#]Qattached? 2 NCH#]Q  '??Q?#^--- 2 0r^#?Q  '??Q?#?--- U2 /?1?#?QIs there a statement justifying the need for MID?    2 /??#?Q  '??Q?#?--- 2 /??#?Q  '??- @ !?#G-- @ !?#H- ???- @ !?#\-- @ !?)#]- ???- @ !?#?-- @ !?7#?- ???- @ !?#?-- @ !?)#?- ???- @ !?#?- ???- @ !?-$G- ???- @ !?-$\- ???- @ !?-$?- ???- @ !?-$?- ???- @ !?-$?- ????]RH--- V2 ^O2HR]?Is there a statement of caregiver status, primary     2 mOHR]?or co 2 mjHR]?- 2 mnHR]?equal? 2 m?HR]?  '????R^--- 2 _r^R??  '????R?--- _2 ^?8?R??Is there a proposal describing requested modifications,    =2 m?!?R??including description of the duti #2 m9?R??es that will be    ;2 }? ?R??performed during the MID period?    2 }H?R??  '????R?--- 2 ^??R??  '??- @ !?QG-- @ !?QH- ???- @ !?Q\-- @ !?)Q]- ???- @ !?Q?-- @ !?7Q?- ???- @ !?Q?-- @ !?)Q?- ???- @ !?Q?- ???- @ !?.RG- ???- @ !??G-- @ !??G-- @ !??H- ???- @ !?.R\- ???- @ !??\-- @ !?)?]- ???- @ !?.R?- ???- @ !???-- @ !?7??- ???- @ !?.R?- ???- @ !???-- @ !?)??- ???- @ !?.R?- ???- @ !???-- @ !???- ???????@Times New Roman- - - --- 2 ?H0  0 2 ?x0  0 )2 ??0  - - -  2 ??0    ???????- @ !?4?H- ???? ?|?H????@Times New Roman- - - - - -  ???????- @ !?&?O- ????- - -  72 ?OH?|?Department/Unit Head Approval       --- 2 ?<H?|?  '?? ???????- @ !?l?|- ???????|--- ???????- @ !?^??- ????--- 2 ?? |???DH Initials --- 2 ??|???  '??- @ !??G-- @ !??G-- @ !?3?H- ???- @ !??{-- @ !?k?|- ???- @ !???-- @ !???- ???- @ !??G- ???- @ !??{- ???- @ !???- ????|?H--- 2 ?OH?|?  ?2 ?R[H?|?__________________________________ is eligible to apply for MID and this application meets      "2 ?OH?|?policy criteria 2 ??H?|?  '?????|--- 2 ??|???  '??- @ !??G-- @ !?3?H- ???- @ !??{-- @ !?k?|- ???- @ !???- ???- @ !??G- ???- @ !??{- ???- @ !???- ????|?H--- 72 ?OH?|?This proposal is in the best  _2 ??8H?|?interest of the unit?s and the school/college?s missions  2 ?H?|?  '?????|--- 2 ??|???  '??- @ !??G-- @ !?3?H- ???- @ !??{-- @ !?k?|- ???- @ !???- ???- @ !??G- ???- @ !??{- ???- @ !???- ????|?H--- ?2 ?ObH?|?Approval of this MID request will not disrupt or cause undue burden to the unit/department/program       2 ?hH?|?  '?????|--- 2 ??|???  '??- @ !??G-- @ !?3?H- ???- @ !??{-- @ !?k?|- ???- @ !???- ???- @ !??G- ???- @ !??{- ???- @ !???- ???!??H????@Times New Roman--- ?2 ?O`H??!SIGNATURE:    .2 ??H??!  2 ??H??!DATE:  2 ?H??!  ????@Times New Roman--- 2 OH??!  --- /2 OH??!  ?2 ?`H??!_____________________________________________ _____________________________ 2 ?H??!  --- 2 O H??!Print Name:    2 ?H??!  '??- @ !??G-- @ !?3?H- ???- @ !??{-- @ !?k?|- ???- @ !???- ???- @ !?3?G- ???- @ !?!G-- @ !?!G-- @ !??!H- ???- @ !?3??- ???- @ !?!?-- @ !?!?- ???- - -  2 +H0   - - -  2 =H 0 Approved by:     2 =?0   ????@Times New Roman--- 2 LH0   ????@Times New Roman---- - - ---- - -  C2 _H%0 _____________________________________           --- 2 _0 _____  - - -  2 _?0   )2 _?0 ____________________       2 _r0   --------- 2 qH0   A2 qx$0   2 q?0   2 q0   +2 q 0 , Dean/Vice President   --- 2 q?0   2 q?0   2 q?0  0--- 2 q?0 DATE  2 q0    ???2 ~H0    ???2 ?H0   ---- - -  C2 ?H%0 _____________________________________           --- 2 ?0 ______   2 ??0  - - -  )2 ??0 ____________________       2 ?r0   ------ 2 ?h0   2 ?o 0 , Provost  2 ??0  --- 2 ??0  0--- 2 ??0 DATE  2 ?0   ? ?"System0 0 8?d --?  00//..% ???? ??՜.??+,??0? hp???? ????? ??Academic Services - KSU?   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