California State Polytechnic University, Pomona 2009-2010 Faculty Furlough Program WINTER 2010 CERTIFICATION BY FACULTY MEMBER

In a ccordance w ith P aragraph 5 .b. o f t he F urlough A greement da ted July 28, 2009, between The C alifornia S tate University and the California Faculty Association, I certify that: i. ii. I agree not to work on mutually agreed or assigned furlough days; and I agree not to work beyond the duties assigned for the furlough week.

Bronco ID#: Print name: _____________________________________ Signature: ______________________________________ Dept.: ____________________ Date: _____________________

Instructions for selecting proposed furlough days: 1. Scheduling of furlough days is by mutual agreement between the faculty member and dean (or other appropriate administrator). Submit proposed dates to the department chair, who will forward the request to the dean. 2. Propose six furlough days for the winter quarter, keeping in mind there can be no more than one furlough day per week and no more than two furlough days per month. 3. As a one-time exception to these limitations, faculty members may observe up to four furlough days in a single calendar month, including up to four furlough days in a single week of that month, during AY 2009-2010. 4. If a furlough day falls on an instructional day, faculty members are encouraged to use best efforts to meet course objectives.

Teaching Schedule (please check appropriate boxes):

Mon

Tue

Wed

Thur

Fri

Sat

Proposed faculty furlough days: January ______ ________ / ______ ________ day date day date February______ ________ / ______ ________ day date day date March ______ ________ / ______ ________ day date day date Total Days Winter: _______________
APPROVAL RECOMMENDED: Yes

If any of these proposed furlough days fall on instructional days, specify the affected class(es):

No __________________________ Date

__________________________________________ Department Chairs Signature APPROVED: __________________________________________ Deans (or other appropriate administrators) Signature
cc: Faculty Affairs Personnel Action File (original)

__________________________ Date