Request for FAC/Administrative Evaluation Faculty Research Support and Service Activities

Evaluation Year _____



Faculty Member Name ______________________________


Use this form to list and describe your Service Activities:


1.  Activity Description













2.  Activity Level _______ (Total Number of Hours Involved with this Activity)



3.  Other Information:







4.  Please attach any supporting documentation.



5.  Activity Evaluation


            _____ By Faculty Member _____By Chairperson    _____ By Committee (if needed)