UNIVERSITY OF CALIFORNIA, DAVIS, SCHOOL OF MEDICINE
VOLUNTEER CLINICAL FACULTY APPOINTMENT FORM
Sections I-VII are to be completed by the applicant (additional pages may be added, if needed):
I. Contact Information
Name: _________________________________________________________________________
Address: _______________________________________________________________________
Telephone: ___________________ Fax: ________________ E-mail: _____________________
II. Education
Degree: ____ Date of Degree: ______ School/Location _______________________________
Training program & Location: ________________________________ Dates: ______________
Training program & Location: ________________________________ Dates: ______________
Specialty: ______________________________________________________________________
ABME Boards (Circle one): Eligible/Certified/Recertified
Date: _____________________
Specialty: ______________________________________________________________________
ABME Boards (Circle one): Eligible/Certified/Recertified
Date: _____________________
III. Teaching Experience (if additional space is needed, place add an extra page)
1) Institution/Location ______________________________________________________________
Role __________________________________________________________________________
Reason for Leaving: _____________________________________________________________
2) Institution/Location ______________________________________________________________
Role __________________________________________________________________________
Reason for Leaving: _____________________________________________________________
IV. Teaching Preferences (Check all that apply):
Setting: ____ UCDMC clinics/wards, ______ free student-run clinics, ____ your own office or hospital,
____ research labs, ____ classroom discussions/small groups, _____lectures/presentations
Level of Trainee: ____ medical students, _____ residents/fellows, _____ grad students/post-docs
V. Do you have research experience?
____ No
____ Yes (please describe below)
VOLUNTEER CLINICAL FACULTY APPOINTMENT FORM, PAGE 2
VI . Numbers of anticipated yearly teaching hours (check one):
____ 50 hrs. or more/yr.
____ 25-49 hrs./yr
____20-24 hrs/yr.
VII: Would you be interested in serving on search committees to identify new faculty members in lieu of
____ Yes
some of your teaching obligations? ____ No
VI. References (Please list 2 professional references and their contact information):
Sections VI-X are to be completed by the department
VI. Department name _____________________________________________________
VIII. Proposed rank _______________________________________________________
IX. Effective Date ________________________________________________________
X. Briefly describe the appointee’s proposed teaching role and how this will benefit the teaching programs
of the department or school:
Department Chair/Division Chief Signature
Date
Dean’s Office Use Only
_______ Approve as proposed (background check: ___pending
____ completed)
_______ Approve with modifications
_______ Not approved
Comments:
Associate Dean’s Signature
Date