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

mm/dd/yyyy

Gender at Birth

What are your preferred pronouns?

What are the last 4 digits of your Social Security Number

Are You of Hispanic, Latino or Spanish Origin?

Please Indicate Your Race

Please select all that apply

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?

Are You A Graduate From The University Of Colorado?

Military Status (Voluntary Disclosure)

Department of Psychiatry – Sponsorship (Please list their name)

Please select which clinical rank you are applying for

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?

Specialty/Subspecialty Of Board Certification

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

Yes

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

Yes

Have you ever voluntarily surrendered your license to practice medicine?

Yes

Have you ever been convicted of a felony crime?

Yes

Have you ever experienced loss of hospital privileges?

Yes

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

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

Drop your files here

Send me a copy of my responses

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