Department of Internal Medicine Appendix #2 - Faculty Reappointment Action Form for Selected Tracks Applicant: __________________________________________ ____________________________ Name MD,PhD,etc Current Faculty Rank Division: ____________________________________________ ____________________________ Initial Faculty Appointment Date
Home Address : _____________________________________ ___ Email : _______________________________________________
Phone: _____________________
For reappointment as : ______ Adjunct (1-49% FTE) ______ Secondary Appointment ______ Volunteer ______ Visiting Description of Job Duties: Teaching/Mentoring (list specific courses, rotations, etc. – attach additional material if applicable):
Research (attach separate listing of scholarly works and/or publications if applicable):
Patient Care:
Service/Administration:
Attachments : ___ CV (Required) If applicable: ___ Annual Evaluation(s) ___ Trainee Evaluation(s) Reappointment Terms: At the rank of: ______________________________________________ For: __________ Year(s) Effective From: _____________________________ To: ________________________________ Recommendation: _____ Approve _____ Disapprove Division Director Department Chair
________________________________ Signature of Division Director / Date Gregory W. Rouan, M.D. / Date Primary Department Chair (Signature for Secondary Reappointment Only)
________________________________
__________________________________________ Primary Department: ______________________ Signature of Primary Department Chair / Date Applicant Acknowledgement : I have read and understand the RP&T criteria and procedures of my college and academic unit, and my rights and responsibilities under the Faculty Policies for Clinical Non-Represented Faculty in the College of Medicine.
__________________________________________ Signature of Applicant / Date
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