Extended Leave Form
Concurrent Instructor Information
Instructor Name: _____________________________________________________________________________
Course(s) Teaching During Leave: _______________________________________________________________
Approximate Dates of Leave: ___________________________________________________________________
Detailed Plan for Coverage
Interim Instructor Name: ______________________________________________________________________
Instructor Email: _____________________________________________________________________________
Phone Number: _____________________________________________________________________________
Describe the interim instructor’s experience, credentials and the communication plan for CEP staff, faculty
mentor and high school administration (attach documentation such as interim's resume and transcripts).
Has this plan to cover the extended leave been communicated with the CEP faculty mentor? Yes_____ No_____
High School Administrator Signature __________________________________________ Date______________
CEP Instructor Signature ____________________________________________________ Date ______________
Please note: This form must be submitted prior to the leave taking place. Once the completed form has been received, the CEP team will
respond with approval, denial, or request for more information.
Scan and email completed form to concurrent@minnesota.edu
For office use only
Plan Denied Pending more information Plan approved
M State K12 Dept. Signature ____________________________________________________________ Date __________________
CONCURRENT ENROLLMENT PROGRAM www.minnesota.edu/concurrent
