Tutee Name(s) Course(s) What, if any, arrangements have been made for ongoing tutor cover for these tutees (include staff names where appropriate)? Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance. Section 3. PG Teaching Commitments Does the staff member have PG teaching commitments which will require cover? YES NO If answer is YES, please indicate: Course(s) Module(s) What, if any, arrangements have been made for the ongoing commitments (include staff names where appropriate)? Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance. Section 4. PGR Supervision Commitments Does the staff member supervise any PGR students? YES NO If answer is YES, please indicate : Name(s) Area of Research What, if any, arrangements have been made for the ongoing supervision of these PGR students (include staff names where appropriate)? Where another member of staff has agreed to cover, please ask them to initial to confirm their acceptance. Section 5. Administrative Duties Does the staff member have key administrative roles which will require cover? YES NO If answer is YES, please indicate: Duty What, if any, arrangements have been made for these commitments (include staff names where appropriate)? Where another member of staff has agreed to cover, please Head of Academic Unit to initial to
Transfer funds to PI Y N Transfer to another internal source Y N Transfer funds to PI Y N Transfer to another internal source Y N Section 8. Equipment Does the staff member have any equipment which was purchased on grants or via University funds? YES NO If answer is YES, please indicate: Item(s) Current location(s) Who will assume responsibility and what will the management arrangements be for this equipment going forward? Head of Academic Unit to initial to confirm agreement Section 9. Samples, slides, data or other items Does the staff member have any samples, animals, slides, data or other items including chemical or radiation which need to be handed over before leaving? Please refer to the section above for any equipment emitting ionising radiation, details of which must be provided. YES NO In particular, does the staff member have any of the following materials: Genetically modified organisms class 1-3 YES NO Pathogens, Hazard Group (HG)2, HG3, Schedule 5 and SAPO YES NO PHO Schedules 1-6 Licenses YES NO Chemical Weapons YES NO Radioactive Materials (open and closed sources) YES NO Lasers YES NO If answer is YES, to (i) or (ii) above, please indicate: Item(s) Current location(s) Who will assume responsibility for their ongoing storage and documentation? What will the local arrangements be for the ongoing management of the above? Please asked any named individuals assuming responsibility to initial here for their agreement Head of Academic Unit to initial to confirm *Additional (see below) * Additional Authorisation: Details of any samples considered under the Human Tissue Act must be forwarded to Dr Christopher Morris, Newcastle Biobanks Governance Team. Dr Morris will initial the form. Details of items identified in subsection (ii) must be forwarded to the Occupational Health and Safety Service (http://www.ncl.ac.uk/ohss/about/contact.htm) who will initial the form.
Section 10. Intellectual Property i. Does the staff member have any vested interest in Intellectual Property Rights (e.g. Patents, Registered Designs): YES NO If the answer is yes, please indicate: a. IPR title(s) and brief description: b. Which Business Development Manager in the Faculty is dealing with this? c. Have arrangements been made to transfer IPR to new institution? YES NO d. If the answer YES to transfer IPR to new institution, please indicate the name of the institution and contact(s): ii. Has the staff member invented any technologies and/or processes which have not yet been disclosed to the University and could potentially qualify for registered (patents, trademarks, registered designs) or unregistered (software, designs, checklists, protocols, questionnaires, toolkits, guidelines, database rights) IP? YES NO If YES, give details below: Section 11. Clinical Staff Does the staff member have any clinical commitments? YES NO If answer is YES, please confirm that you have notified the appropriate NHS organisation(s) YES NO Section 12. Authorisation We confirm that satisfactory arrangements are in place to cover all commitments as indicated above: SIGNED : __________________________________ STAFF MEMBER DATE : ___________________
SIGNED : ____________________________________ HEAD OF SCHOOL/DIRECTOR OF INSTITUTE DATE : ___________________ Please send copy of form to : Ms Katharine Rogers Director of Faculty Operations Faculty Office Faculty of Medical Sciences Newcastle University Medical School Framlington Place NE2 4HH Reviewed by FSG: YES NO Date: Approved on behalf of FSG __________________________________ SIGNATURE ___________________________________ PRINT NAME Data Protection statement: The University will process the data provided on this form in accordance with the HR privacy notice which can be found on our website at