Medical Director Nomination Form

This form should be used to nominate physicians into medical director roles, or make changes to the allocation of time the medical director will dedicate to medical director duties. Please reach out to Stephanie Hatcher with any questions or concerns: stephanie.n.hatcher@vumc.org 615.875.9907

Date Requested

Today's date

Requestor*

What role is this appointment for?*

eg. 8CCT - Medical ICU, Antimicrobial Stewardship, Transplant PCC, etc.

Who is the nominating department chair?

Name of the department chair making the nomination. This is who the reviewing parties will reach out to with any questions.

Is this a replacement request, a new medical director position, or a reallocation of effort?*

New - Requesting unbudgeted resources for a medical directorship that does not currently exist (enter the new nominee's name in "Nominee" section)

Replacement - Nominating a new appointee into an existing role (Enter the new Nominee's name in "Nominee" section)

Reallocation - Changing the amount of time allocated for the medical director to dedicate to medical director duties (enter the existing medical director's in "Nominee" section)

Replacement and reallocation

What is the nominee's name and credentials

eg. John Doe, MD, MPH

Who will this nominee be replacing?

if this is a new position, leave blank

How much of the nominee's FTE will be allocated to medical directorship duties?

Please enter as a partial FTE (eg. "0.1")

What is the 12 month salary cost and fringe benefit that will be paid for medical director duties?

(Annual salary & fringe cost X Requested FTE allocation = Annual Medical Director Salary Allocation)

What are the nominee's qualifications for the role?

Short description of appointee's experience justifying them as a good fit for the role

Does this appointee have any effort allocated to the VA? If so, how much?

Please describe the effort and indicate how much of the appointee's time is dedicated to the VA. If none, leave blank.

Does this appointee have any time allocated to other non-clinical duties? If so, how much?

Please describe this effort and how much time is dedicated.

Notes

Any additional information you would like to include regarding the nomination.

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