UNIVERSITY
NAME:
of
PENNSYLVANIA
-- REQUEST FOR APPROVAL (PART I)
Date:
____ Citizenship:
USA
Other (specify)
Visa Type
John S. Doe, M.D.
The reappointment of Dr. John S. Doe as Professor of Clinical (Please fill in the name of your Department) in the
Associated Faculty of the Perelman School of Medicine for five years effective July 1, 2005 (full salary; not in
tenure probationary status in this appointment).
Proposed by:
Approved by:
School
Perelman School of Medicine
Department
(Please fill in the name of your Department)
Committee on Appointments and Promotions, Perelman School of Medicine ___________________________
Standing Committee of Departmental Chairmen _________________________________________________
Forwarded by: Dean or Dean's Representative _______________________________________
PRESENT POSITION:
Date: ________________
(Leave blank for persons not presently affiliated with the University of Pennsylvania)
Dates: 7/1/00-6/30/05
Title:
Professor of Clinical (Please fill in the name of your
Department)
Faculty Status:
Salary Status:
____ Salary Source:
Standing Faculty
Full Salary
Dept. budget A-2
A-1 budget
Tenure Status: (with dates)
Associated Faculty
Partial Salary
Grant(s)
Other (specify)
No Salary
Clinical Group
Not in tenure probationary status in this appointment.
PROPOSED POSITION:
Dates:
7/1/05-6/30/10
Faculty Status:
Salary Status:
____ Salary Source:
Title:
Standing Faculty
Full Salary
Dept. budget A-2
A-1 budget
X
Tenure Status: (with dates)
Professor of Clinical (Please fill in the name of your
Department)
X
Associated Faculty
Partial Salary
Grant(s)
Other (specify)
No Salary
Clinical Group
Not in tenure probationary status in this appointment.
FACULTY APPOINTMENT HISTORY: (at the University of Pennsylvania)
Dates
7/1/00-6/30/05
PSC ACTION TAKEN:
Approved
Other
Title and Department
Affiliation/Salary Status
Professor of Clinical (Please fill in the name of your Department)
F/F
Date of Provost’s Staff Conference:
Not Approved
Conditionally Approved