Full Time Faculty Committee Assignment Request Form

Full Time Faculty Assignment Committee Assignment Request Form

Please submit the Committee Assignment Request form to the Office of Instruction by April 28th.

General Information

Select your email(Required)

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Assignment

Committee Detail Selection.

I will serve on two committees. My committee preferences are indicated below.

I will serve on one committee and am requesting Alternative Committee Service. [Select the Alternative Assignment box and at least one preferred committee; complete the alternative assignment request]

I serve as a Dental Hygiene faculty member

I will serve as a Chair or Co-chair on one committee. [Select the Chaired preferred committee]

Select Committee

Preferred/Required	Select a Committee	Actions
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Add as many committees as indicated by your selection above.

Alternative Committee Service

Describe the nature of the alternative service for which you are requesting approval. Enter the information in the area below and/or attach document(s). Provide enough information so that your request may be evaluated for approval by the supervising Vice-President.

If your request for Alternative Committee Service is approved by the supervising Vice-President, a copy of this form will be returned to you. (Note: A minimum of ten (10) hours of Alternative Committee Service is needed to fulfill one committee assignment. Alternative Committee Service must be completed by the end of the current academic year.)

Possible examples of Alternative Committee Service include but are not limited to the following: Service on an institution workgroup such as DEIAA, Curriculum Tech Review, multiple campus committees that meet more than 10 hours a year, service on accreditation committees, new program development, a Faculty Peer Mentor, and special projects.

Description of Alternative Committee Service: (include the number of hours necessary to complete the alternative service; add attachments as needed)

Alternative Committee Service

Alternative Service

Signature

Date

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