Non-Teaching Clinical Volunteer Application

Non-Teaching Clinical Volunteer Application

THIS APPLICATION SHOULD NOT BE FILLED OUT IF YOU ARE PLANNING TO INSTRUCT/TEACH AT ALL, PLEASE EMAIL JOSEPH.SAKAI@CUANSCHUTZ.EDU IF YOU HAVE ANY QUESTIONS OR CONCERNS

Demographics

Last Name*

First Name*

Credentials*

Physical Address*

Please include your street address, city, state and ZIP

Best Contact Telephone Number*

Best Contact Email Address*

Date of Birth*

Gender at Birth*

Select

What are your preferred pronouns?

Select

What are the last 4 digits of your Social Security Number*

Are You of Hispanic, Latino or Spanish Origin?

Select

Please Indicate Your Race

Please select all that apply

Select

Current Job Role/Position

Name of clinical site*

Clinical site phone number*

Phone

Clinical site address*

Please include street address, city, state and ZIP

Name of office manager*

Office manager email*

What is your highest level of education?*

Select

Are You A Graduate From The University Of Colorado?

Select

If yes, which campus(es) did you graduate from?

Please select all that apply

Select

Which program(s) did you participate in?

Military Status (Voluntary Disclosure)

Select

Department of Psychiatry – Sponsorship (Please list their name)

Please select which clinical rank you are applying for*

Select

Please describe how you will meet the criteria for this rank*

For assistance, please see descriptions in Guidelines for appointments, promotions and review/reappointment/termination clinical (voluntary) faculty, Clinical Faculty Guidelines for Psychiatry

Please describe your anticipated role, what will you do and how many credit hours do you anticipate?*

Medical Licensing And Professionalism

Medical License #

Do you have a DEA Certificate?*

Select

DEA Certificate Number & Expiration Date*

Specialty/Subspecialty Of Board Certification*

Has your medical license ever been denied, limited, suspended, or revoked in any state?*

Yes

No

Are you currently the subject of a formal complaint regarding your medical license?*

Yes

No

Have you ever voluntarily surrendered your license to practice medicine?*

Yes

No

Have you ever had a DEA licensing investigation or action?*

Yes

No

Have you ever been convicted of a felony crime?*

Yes

No

Have you ever experienced loss of hospital privileges?*

Yes

No

Are you currently abusing or excessively using any habit forming drug, including alcohol or any illegal or controlled substance in a way that interferes with your ability to meet your professional responsibilities or that affects your ability to practice safely and competently?*

Yes

No

I further agree to notify the department where I hold my faculty appointment in a timely manner (not to exceed 30 days) of any change to the information related to the information provided above*

I agree

I do not agree

Please attach your CV and malpractice insurance in the drop box below*

Drag and drop files here or

Send me a copy of my responses

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