ACADEMIC APPOINTEE
RECOMMENDATION FORM
Candidate’s name
New Hire
Center or
Division
Degree
Current UCLA Employee, list department & payroll title:
Proposed series & step:
Begin date
Candidate’s
phone #
End date (if appropriate)
Is appointment WOS?
YES
Is candidate a U.S. citizen?
If NO, enter percentage of time
NO
YES
If NO, visa type
NO If NO, is candidate a permanent resident?
YES
NO
Expiration date
Is candidate to be a member of the Departmental Practice Plan?
Is candidate licensed to practice in California?
Is candidate going to personally treat patients?
Is candidate going to supervise residents?
Is candidate going to bill through the practice plan?
Is candidate going to be responsible for signing
and/or countersigning medical records?
YES
YES
YES
YES
YES
YES
NO If yes,
NO Specify type
of license
NO
NO Specify
candidate’s
NO specialty
NO
MCP
BSCP
Major duties (including patient care, administration & teaching assignments) must be specified in the
required recommendation letter. A completed Faculty Compensation Worksheet is also required; please
do not include pending awards as funding sources.
Means of compliance with equal opportunity employment regulations:
Please ensure that the following are attached:
DIVISION DIRECTOR or CENTER
DIRECTOR or AFFILIATED HOSPITAL
PROGRAM DIRECTOR
Completed Faculty Compensation Worksheet (if applicable)
Current Curriculum Vitae
Letter of Recommendation
Letter of Understanding (LOU) (if applicable)
Commitment Checklist (if applicable)
APPROVALS
DATE
MEDICAL DIRECTOR or
EXECUTIVE CHAIR
FOR PERSONNEL USE ONLY
PSO
IS
Privileges
Billing Number
Access to CDS
VISA
SPACE
Needs Visa
Visa in progress
Assign space
FYI
rev 1/00