ࡱ> c bjbj 4DKbKb ^ ^ 8&$JI666$ R66666H@&&&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 units and the school/colleges 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 : @ DEֻతజజȊజh"]Wh 5CJh`CJaJh CJaJhh :CJaJhh CJaJ jhh 5CJh 5CJh`5CJhh 5CJhh CJhh 5>*CJh"h 5CJ6;<H I v w mxkd$$Iflr'r'  t 0r'44 lalp yt` $Ifgd $a$gd $a$gd    Z [ \ ] @kd$$Ifl4\>$r'>v`6` t0r'44 lalp( $Ifgd ] ^ I@4&$Ifgd o $$Ifa$gd $Ifgd kds$$Ifl4\>$r'>v 6  t0r'44 lalp( ) * <3' $$Ifa$gd $Ifgd kdK$$Ifl\>$r'>v6 t0r'44 lalp($Ifgd o* c d e <3 $Ifgd kd$$Ifl\>$r'>v6 t0r'44 lalp($Ifgd o 6 7 $Ifgd o,$Ifgd $$Ifa$gd 7 8 J:$,$Ifa$gd`kd$$Ifl\>$r'>v6 t0r'44 lalp( { $Ifgd xkd$$Iflr'r'  t 0r'44 lalp yt` EFGssjj^jj $$Ifa$gd $Ifgd ,$Ifgd kdG$$Iflr'r'  t 0r'644 lalgp yt`EFG'123fg23IJghsu9;ƿƝ{hh CJ aJ hh CJaJhh 5CJaJhh CJaJh h 5CJ jhh 5CJh 5CJhh 5CJh h CJh CJaJhh CJaJhh CJh h CJaJ.CH?3? $$Ifa$gd $Ifgd kd$$Ifl\5$r'5Hv t0r'644 lalg%$If^%`gd Cu?7$a$gd kd$$Ifl\5$r'5Hv t0r'644 lalg%$If^%`gd $Ifgd 23ef|p[$If]^`gd $$Ifa$gd zkdI$$Iflr'r'  t 0r'644 lalp yt` $Ifgd fg12^UIU4$If]^`gd $$Ifa$gd $Ifgd kd$$Ifl\>$r'>vHv t0r'644 lal23Jht^YPP $Ifgd gd kd$$Ifl\>$r'>vHv t0r'644 laltug^^ $Ifgd kd- $$Ifl0 !`' !T  t0`'644 lalpyt`9:{{ $Ifgd zkd $$Ifl0 !`' !T t0`'644 lal:;{{ $Ifgd zkdv $$Ifl0 !`' !T t0`'644 lal{{{{ $Ifgd zkd $$Ifl0 !`' !T t0`'644 lalKLMxv ^`gd)gd ^`gd gkd $$Ifl`'`' t0`'644 lal$,CEFKMry龷ݮ鍾ݣwswswswshdhdsh"hh"CJaJh_thh_tCJjhh_tCJUh)5CJhh B*CJaJphhh CJaJh)5CJaJh 5CJhh 5CJh 5CJaJhh 5CJaJhh 5CJaJhh 5CJaJhh CJaJ' ^`gd)gd hh CJaJ21h:p / =!8"#h$% $$Ifl!vh#vr':V l  t 0r'5r'alp yt`$$Ifl!vh#v>#vv#v6#v:V l4 t0r'++5>5v565alp($$Ifl!vh#v>#vv#v6#v:V l4 t0r'++5>5v565alp($$Ifl!vh#v>#vv#v6#v:V l t0r'5>5v565alp($$Ifl!vh#v>#vv#v6#v:V l t0r'5>5v565alp($$Ifl!vh#v>#vv#v6#v:V l t0r'5>5v565alp($$Ifl!vh#vr':V l  t 0r'5r'alp yt`$$Ifl!vh#vr':V l  t 0r'65r'algp yt`$$Ifl!vh#v5#v#vH#vv:V l t0r'65555H5valg$$Ifl!vh#v5#v#vH#vv:V l t0r'65555H5valg$$Ifl!vh#vr':V l  t 0r'65r'alp yt`$$Ifl!vh#v>#vv#vH#vv:V l t0r'65>5v5H5val$$Ifl!vh#v>#vv#vH#vv:V l t0r'65>5v5H5val$$Ifl!vh#v !#vT:V l  t0`'65 !5Talpyt`$$Ifl!vh#v !#vT:V l t0`'65 !5Tal$$Ifl!vh#v !#vT:V l t0`'65 !5Tal$$Ifl!vh#v !#vT:V l t0`'65 !5Talw$$Ifl!vh#v`':V l t0`'65`'als666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@PJ_HmH nH sH tH @`@ (TNormalCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k (0No List jj PY Table Grid7:V04@4 3;0HeaderH$.. 3;0 Header Char4 @"4 3;0FooterH$.1. 3;0 Footer CharPBP 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].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<v D E ! ] * 7 Cf2t:  T # @H 0(  0(  B S  ?  8:E F o"(<_t&'&)%5+Wh9DQ `y @    @UnknownSUSANA L. 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ZH  1.@Times New Roman--- 2 >H0    0''@Times New Roman--- 2 H0    0''@Times New Roman--- 2 O0   @Times New Roman--------- a2 `90 Modified Instructional Duties (MID) Application Checklist    --- 2 `^0  @Times New Roman---- @ !tb- --- 2 p0    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 OHEligibility Criteria   2 H* 2 H  2 H- 2 H  2 HAll  ,2 Hitems in this section   2 qHmust be  2 Hchecked 2 H  :2 Hto 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 8Is the applicant the primary caregiver of a child?, or,   2    ^2 7Is 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 %27Is the request within 12 months of the qualifying     2 47event? 2 47  '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  'f8^--- 2 Er^8f  'f8--- 2 D8fIs the  L2 D+8fperiod of time being requested for the MID     f8'' 2 S 8fallowable?  2 S8f  f8'''f8--- 2 D8f  '- @ !7G-- @ !7H- - @ !7\-- @ !)7]- - @ !7-- @ !67- - @ !7-- @ !*7- - @ !7- - @ !.8G- - @ !.8\- - @ !.8- - @ !.8- - @ !.8-  - @ !gH-  vgH@Times New Roman- - - ---- - - ---- - - --- - @ !gO-   2 sHgv*  2 sHgvN - - -  2 sHgvOTE--- 2 sHgv:- - -  2 sHgv --- q2 sDHgvFaculty are ineligible if they have been denied tenure or received N  2 s Hgvotice of  2 sCHgvN  2 sLHgvon 2 sZHgv- 2 s^HgvR 2 sf Hgveappointment  2 sHgv  vgH'''- @ !fG-- @ !fH- - @ !f\-- @ !)f]- - @ !f-- @ !6f- - @ !f-- @ !*f- - @ !f- - @ !gG- - @ !vG-- @ !vG-- @ !vH- - @ !g- - @ !v-- @ !v- --- 2 H0    - @ !H-  H--- - @ !O-   =2 O!HDepartmental 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 8Has the applicant requested a delay in the tenure clock?  2   ------ R2 /[ ] Yes [ ] No [ ] N.A.   --- 2 Q  '--- 2   '- @ !G-- @ !H- - @ !\-- @ !)]- - @ !-- @ !7- - @ !-- @ !)- - @ !- - @ !2G- - @ !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- - @ !-- @ !)- - @ !- - @ !2G- - @ !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 NH#]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 mHR]  'R^--- 2 _r^R  'R--- _2 ^8RIs there a proposal describing requested modifications,    =2 m!Rincluding description of the duti #2 m9Res that will be    ;2 } Rperformed during the MID period?    2 }HR  '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    - @ !4H-  |H@Times New Roman- - - - - -  - @ !&O- - - -  72 OH|Department/Unit Head Approval       --- 2 <H|  ' - @ !l|- |--- - @ !^- --- 2  |DH Initials --- 2 |  '- @ !G-- @ !G-- @ !3H- - @ !{-- @ !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-- @ !3H- - @ !{-- @ !k|- - @ !- - @ !G- - @ !{- - @ !- |H--- 72 OH|This proposal is in the best  _2 8H|interest of the units and the school/colleges missions  2 H|  '|--- 2 |  '- @ !G-- @ !3H- - @ !{-- @ !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-- @ !3H- - @ !{-- @ !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-- @ !3H- - @ !{-- @ !k|- - @ !- - @ !3G- - @ !!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$0   2 q0   2 q0   +2 q 0 , Dean/Vice President   --- 2 q0   2 q0   2 q0  0--- 2 q0 DATE  2 q0    2 ~H0    2 H0   ---- - -  C2 H%0 _____________________________________           --- 2 0 ______   2 0  - - -  )2 0 ____________________       2 r0   ------ 2 h0   2 o 0 , Provost  2 0  --- 2 0  0--- 2 0 DATE  2 0    "System0 0 8d --  00//..% ՜.+,0 hp  Academic Services - KSU   Title  !"$%&'()*,-./0123456789:;=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F`NData #1Table+ WordDocument4DSummaryInformation(<DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q