CAREER STAFF DEVELOPMENT FEE ASSISTANCE PROGRAM ...

CAREER STAFF DEVELOPMENT FEE ASSISTANCE PROGRAMAPPLICATION PROCEDURE AND CHECKLISTCompleted applications will be accepted either two months prior to the start of the course (withaccompanying registration receipt) and up to two months following the completion of the course (withregistration receipt AND transcripts). Please note that ALL awards require transcript documentation asdescribed in detail below.Send your completed applications to:ProcessCareer Staff Development Fee Assistance CommitteeThe Office of Campus Community RelationsUC Davis; 530-754-7987 (fax) to the attention of Tammy McNiffOr email to: tdmcniff@ucdavis.eduApplications are reviewed monthly. Applicants will be notified by email regarding disposition(approval/denial) of the request. If you have questions regarding your application, please call Tammy McNiff,530-752-2071.Conditions of Award Employees must be career staff employees with a minimum of one year of service. Training must assist the employee in obtaining his/her career goals at UC Davis. Only fully completed and timely applications will be reviewed. Incomplete applications will be returned tothe employee. Employees funded through this program must submit Proof of payment for program registration at the time the application is submitted proof of satisfactory completion (e.g., transcript or official course grade) within two months of thelast class day of the course. Failure to provide proof of completion will result in the employee beingheld financially liable for all funded costs. Send proof to:Career Staff Development Fee Assistance CommitteeThe Office of Campus Community RelationsUC Davis530-754-7987 (fax) to the attention of Tammy McNiffOr email to: tdmcniff@ucdavis.eduFee Assistance Award Procedure Payment of award will be made upon approval of the application. No retroactive payments will be made. Up to $600 may be awarded in a fiscal year to cover actual course/registration fees only. Up to $1,500 maybe awarded for a degree or certificate program. (A maximum of $300 are given per application request.)Other InformationAdditional application forms may be obtained on the web at http://www.hr.ucdavis.edu/sdps/forms/sd-ps-formsand-downloads. Questions may be directed to Tammy McNiff, (530) 752-2071 (tdmcniff@ucdavis.eduApplicant Checklist_____1._____2._____3._____4.3-Page Application for Affirmative Action Fee PaymentCopy of course announcement/description with dates and fees.Proof of payment for course (original receipt)Survey for Statistical Purposes____________________________Date application submitted.

CAREER STAFF DEVELOPMENT FEE ASSISTANCEFOR CAREER-RELATED EMPLOYEE DEVELOPMENT PROGRAMAPPLICATIONS MUST BE RECEIVED NO LATER THAN THE 5TH OF THE MONTHPRIOR TO THE MONTH THAT THE COURSE BEGINSInstructions: Complete this application form for the course fee(s) requested. Attach a completed “Surveyfor Statistical Purposes” sheet - then send to:Career Staff Development Fee Assistance CommitteeThe Office of Campus Community RelationsUC Davis; 530-754-7987 (fax) to the attention of Tammy McNiffOr email to: tdmcniff@ucdavis.eduPlease print or type legibly.Employee NameHome AddressWork PhoneStreet City State ZipE-mailYears of Service with UCYears of Service in Present PositionDepartment Workplace: Campus UCDHSPayroll TitleName of Course(s)Work Hours*Number of UnitsNumber of UnitsDate(s) of Course(s): BeginEndTime of Course(s)* Own Time or Work TimeTraining Institution NameCourse Fee(s)course(s) description):(attach receipt for fees) and brief description of course(s) (attach a copy of

*This portion must be completed if the course is scheduled during employee’s normal working hours.TIME FOR COURSE ATTENDANCE:Approved as time workedAPPROVEDRevised 07/2010SupervisorTemporary work schedule adjustmentDatePERSONAL STATEMENT OF PURPOSEAnswer the following questions completely. Incomplete applications will be returned. Use additional paper ifnecessary.1. Briefly describe your present job duties.

2. Fully describe your career goals at UC. (An Employee Development Plan may also be attached.)3. Degree or Certificate Objective:4. Explain how this course/program relates to your career goals.5. I have completed the following course(s) or program(s) toward meeting my UC career goals:Course Name Date Completed Institution/Agency

6. Future coursework that I am planning to take in order to upgrade my skills and to meet my UC career goals:Course Name Date Offered Institution/Agency7. Have you previously applied for Affirmative Action funds? Yes NoIf yes, were you awarded funds? Yes No If yes, when amount $8. Do you expect to receive other UC funds to help pay for this course: Yes NoSource Amount $I meet the criteria for this application and I have:completed all information as requested,attached a course description.Employee Signature Work Phone DateSubmit completed application materials to:Career Staff Development Fee Assistance CommitteeThe Office of Campus Community RelationsUC Davis; 530-754-7987 (fax) to the attention of Tammy McNiffOr email to: tdmcniff@ucdavis.edu

CAREER STAFF DEVELOPMENT FEE ASSISTANCE APPLICATIONSURVEY FOR STATISTICAL PURPOSES ONLYTo assure full compliance with Federal and State Equal Opportunity/Affirmative Action requirements, theUniversity collects and maintains statistical data on employees participating in training programs. Data will beutilized for compliance and statistical purposes only and will be kept confidential. Providing this information isvoluntary. Non-completion of this section will not preclude, enhance or detract from your opportunity toparticipate in this program.Please check one only:Check any applicable:I. WHITE (Not of Hispanic origin) Male(F) WhiteFemaleII. BLACK (Not of Hispanic origin) (H) Disabled(A) Black/African American(V) Vietnam Era Veteran(S) Special Disabled Veteran(E) War/Campaign/Expedition VeteranIII. ASIAN OR PACIFIC ISLANDER(2) Chinese/Chinese-American Time Designation:(B) Japanese/Japanese-AmericanRelease Time with Pay(L) Filipino/PilipinoAdjusted Work Schedule(R) Pakistani/East IndianOwn Time (Outside Regular Work Hours)(X) Other AsianIV. AMERICAN INDIAN OR ALASKAN NATIVE(C) American Indian or Alaskan NativeFOR STAFF DEVELOPMENTUSE ONLYFederal Occupational Codes:_____ Officials/Managers_____ ProfessionalsV. HISPANIC(E) Mexican/Mexican-Amer./Chicano(5) Latin-American/Latino _____ Technicians(W) Other Spanish/Spanish-AmericanNAME:DEPARTMENT_____ Office & Clerical Workers_____ Operatives_____ Other _________________EMPLOYEE IDENTIFICATION NUMBER:DATE:FEDERAL PRIVACY NOTICEIn accordance with the Federal Privacy Act of 1974, you are hereby notified that disclosure of your EmployeeIdentification number is voluntary. This recordkeeping system was established pursuant to the authority of TheRegents of the University of California under Article IX, Section 9, of the California Constitution. Theprincipal use of the number is to verify your identity in the staff development record system for producingperiodic reports related to affirmative action as required by the U.S. Department of Labor.Revised 12/2010