Please read the program guidelines prior to completing this application. Incomplete applications not containing original receipts and evidence of completion will be returned. PERSONAL INFORMATION First Name MI Last Name Are you known by a different name at your educational institution? Yes No If yes, what name? PPS ID No. Title Department Name Permanent/Home Mailing Address Street City State Zip Is this a new address? Yes No Note: Reimbursements are mailed to the address on file with Payroll. Work Address Building Name Contact Information Work Phone Number Suite/ Room No. Personal Phone Number Preferred E-mail Address EMPLOYMENT INFORMATION Length of service with UCDHS Years Months Are you are career employee? Yes No Are you currently on a leave of absence? Yes No If yes, please specify type of leave: If yes, what is your expected return to work date? (MM/DD/YY) Note: Special conditions may apply to employees on leave. Have you had any corrective action in the last 2 years: Yes No If yes, please explain: Training & Development STEP Application Page 1 of 5 Rev2014.0305
EDUCATIONAL INFORMATION I am currently pursuing one of the following: An accredited matriculated (degree-seeking) program An accredited health sciences vocational program Prerequisite courses towards a matriculated program Name of Educational Institution Name of Degree/Vocational Program Program Type (AA, BA, etc.) Program Began (MM/YY) Anticipated Completion (MM/YY) STATEMENT OF PURPOSE Please state how this training will aid you in accomplishing your career goals at UC Davis Health System: CAREER DEVELOPMENT PLAN All coursework for which reimbursement is sought must support the employee's stated career objectives. A new Career Development Plan must be filed if there is a change of degree program and/or career objective. Please list your educational background, most recent degree listed first. Educational Institution Degree Major Year Attained Career Objectives What is your long-range career objective with UCDHS? Training & Development STEP Application Page 2 of 5 Rev2014.0305
What, if any, intervening positions will you need to obtain in order to reach your final objective? Describe how this degree or course of study will assist in accomplishing your long-range career objective. Please list the classes you intend to complete as part of your matriculated degree/vocational program. You may attach a copy of the degree/vocational program or additional sheets as needed. Course Title Units Quarter/Semester Year Cost Estimated Total Cost of Program $ Training & Development STEP Application Page 3 of 5 Rev2014.0305
FUNDING INFORMATION Are you currently participating in a University reduced/discounted tuition program? Yes No Did you receive grant or scholarship funding that was used to pay for this training? Yes No Are you receiving other funding for the specified training? Yes No If yes, please specify: Today s Requested Reimbursement Please specify reimbursement type (tuition, books). See guidelines for eligible expense categories. of Expense Reimbursement Type Amount Total Amount Requesting $ EMPLOYEE CHECKLIST Please check the boxes and sign to acknowledge understanding of the STEP Program. I have read the program guidelines and understand that failure to comply could result in a reimbursement delay, denial of reimbursement, or a reimbursement repayment to UCDHS. I have attached the following with this application in the specified format noted in the program guidelines Original itemized receipts indicating amount paid and form of payment Proof of passing quarterly/semester grades I understand it may take 4 6 weeks to receive reimbursement. I understand if I am to separate/terminate as a career employee from UCDHS or have an appointment change to an ineligible appointment type prior to completion of any pending funding process, I am no longer eligible for reimbursement. Pending requests will be immediately voided. I understand employees are responsible for any tax liability resulting from employer provided tuition assistance. The University is required by law to report to the Internal Revenue Service the amount of tuition assistance received that is subject to taxes. I acknowledge the Career Development Plan serves as a tool to guide me in achieving my career objectives, and does not guarantee promotion or any other career advancement as a result of completion of this plan. I certify the information provided on this application is true and complete. Employee Signature Training & Development STEP Application Page 4 of 5 Rev2014.0305
TO BE COMPLETED BY EMPLOYEE S SUPERVISOR UCDHS Supervisor s Name (Please Print) Supervisor s Phone Number Email Address Career employee Yes No Probation complete Yes No Corrective action within last 2 years Yes No Satisfactory performance appraisal Yes No Employee s performance Exceeds expectations Meets expectations I certify this information is true and complete. UCDHS Supervisor s Signature SUBMISSION GUIDELINES Please read the program guidelines prior to completing this application. Incomplete applications not containing original receipts and evidence of completion will be returned. All documents and receipts should be hand-delivered or sent via inter-office/u.s. mail to the Human Resources Training & Development Unit at the following address: UCDHS Human Resources Training & Development, Room 2600 2730 Stockton Blvd. Ticon III Bldg., Sacramento, CA 95817 TO BE COMPLETED BY TRAINING AND DEVELOPMENT Training and Development Reviewer Training & Development STEP Application Page 5 of 5 Rev2014.0305