Clinician Educator - New Appointment Request Form

Please complete and submit this form six months before the start date of this action.

Faculty Last Name*

Faculty First Name*

Division*

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File Upload*

Please upload CV (required).

Please also upload any letters of evaluation that may have been solicited/provided during the search process.

Drag and drop files here or

Proposed Rank*

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Division Chief Justification for recommended rank*

Provide the Division Chief's justification to support reputation/recognition. For Clinical Associate Professor actions, provide evidence of regional reputation. For Clinical Professor actions, provide evidence of national reputation. This justification should be about a paragraph in length and based on the criteria in the School of Medicine Faculty handbook.

Resources:

Rank-specific supplementary criteria, SoM Faculty Handbook.

Regional and national reputation guidelines/examples, SoM Dean's Office.

Proposed Effective Date*

Term Length (Clinical Instructors only)

Total FTE (%)*

i.e. 100% instead of 1.0

% Effort for clinical duties*

Overall total effort must equal 100 percent irrespective of appointment FTE

% Effort for research duties

Must have internal or external funding (cannot be charged to clinical account)

% Effort for teaching duties*

At minimum 5% required for bedside teaching

% Effort for administrative duties

How was the candidate identified and selected?*

Please also describe the evaluation method used to select the top candidate.

Recruitment ID*

Was a search conducted?*

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Was the position advertised?*

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Was a search committee formed?*

Select

Search Committee Chair

Search Committee Members

Describe outreach efforts*

How many candidates applied?*

How many candidates were interviewed?*

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