TEACHERS OF QUALITY ACADEMY
Faculty Application Form
APPLICANT INFORMATION
Last Name
First
M.I.
Degree:
Address
City
State
Phone
E-mail
ZIP
College/School
Department
Circle one:
Division
Tenured
Assistant Name
Tenure Track
Fixed Term
Rank
Adjunct
Affiliate
Email
Other:
Phone
NOMINATED BY:
Name
Relationship
Department
Phone
Email
What motivated you to apply for the Teachers of Quality Academy?
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Please describe any prior training or experience you have in Patient Safety, Quality Improvement, Teaching,
Team training and/or other relevant skills that will contribute to your Teachers of Quality Academy experience.
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Please attach a copy of your full Curriculum Vitae.
I understand that it is an honor to become a member of the Teachers of Quality Academy and involves a
commitment to a year of training followed by ongoing participation in a local learning community and mentoring
of learners in health system science. I am willing to complete the training requirements, develop and complete
projects, train students and colleagues in these endeavors, and participate in research and/or publications related
to these projects. Additionally, participation in the program is contingent on completion of the IHI Modules prior
to August 15th, 2016.
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Signature
___________________________________
Date
Please return this form to garrisj15@ecu.edu by Monday, May 2, 2016.