The Warren Alpert Medical School of Brown University
Clinical Faculty Review Form
Submit form to Division Director, Hospital Chief, or Department Administrator
Name: Click here to enter text.
Initial Year of Appointment: Click here to enter text.
Department: Choose an item.
Division/Specialty: Click here to enter text.
Office Address: Click here to enter text.
Office Phone: Click here to enter text. Ext: Click here to enter text. Fax: Click here to enter text.
Email: Click here to enter text.
Hospital affiliation:
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Clinical Faculty rank:
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Track:
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List teaching or service activities below with emphasis on recognized, formal teaching activities relating to Brown
medical students, residents and fellows.
Teaching or Service Activity
Level and Number of
Frequency (# of hours per
Learners
week/month/year)
Inpatient teaching attending
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Resident in the office
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Resident in the office-on match
list but not chosen
Physical diagnosis preceptor
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Preceptor, 3rd year student
clerkship
Outpatient clinic preceptor
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Subspecialty or GIM service
attending
Pathophysiology course preceptor
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The Doctoring Program
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Brown University Annual Clinical Faculty Review
Additional Information
Page 1
List teaching activities on the grid below with emphasis on recognized, formal teaching activities relating to Brown
medical students, residents and fellows.
Teaching or Service Activity
Level and Number of
Frequency (# of hours per
Additional Information
Learners
week/month/year)
Bedside teaching (documented)
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Resident Advisor
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Student advisor in PLME or
medical school
Tutorial preceptor for
students/residents and/or fellows
Morning report participant
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Grand Rounds, M&M Conference,
subspecialty conference presenter
Journal Club Presenter
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Book or journal article
publications
Hospital/University committee
member or chair
Professional organization
leadership
Participation in subspecialty
conferences
Office Research/Other
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Total Number of Hours
Documented:
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Additional information relevant to the appointment/reappointment process may be included on a separate page.
Teaching evaluations are required for reappointment and can be obtained through Oasis and E*Value. Contact course
facilitator for assistance.
Updated CV Enclosed: ☐
Teaching Evaluations enclosed: ☐
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Faculty Signature
Date
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Division Director/Hospital Chief Signature
Brown University Annual Clinical Faculty Review
Date
Page 2