Attachment 1
The Ohio State University
College of Medicine
Documentation of Auxiliary Faculty Scholarly Activity
In the summer of 1994, the OSU Board of Trustees approved amendments to Faculty
Rule 3335-5-19, which governs the appointment and promotion of auxiliary faculty.
New rules call for departments to review auxiliary faculty appointments annually to determine the level of their contributions to the University. In order to accomplish this, we are asking that you provide the following information concerning your teaching and other scholarly activities during the previous academic year related specifically to The
Ohio State University medical students and other trainees. When you have completed this brief form, please sign and send it with a copy of your current CV to the medical education director in the hospital where you are affiliated and ask him or her to sign in the appropriate space. The form must then be sent to the
Chair of Surgery, E. Christopher Ellison, M.D., 395 W 12 th Ave, Rm 692,
Columbus, OH 43210 for approval.
Thank you for taking the time to respond to this important questionnaire. If you have questions, please contact the OSU Department of
Surgery Chairman’s office (614-293-8701).
Name: __________________________________________
OSU Faculty Rank:
Specialty/Subspecialty:
Address:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Telephone: __________________________________________
Time interval of this report is July 1, 2009 to June 30, 2010.
Location of Teaching Activity (please mark all appropriate categories.)
_____ Private Office
_____ OSU Hospitals Clinic (Outpatient)
_____ OSU Hospitals (Inpatient)
_____ Other Hospital or Site (please specify)
_____________________________________________________________________

Describe your formal teaching activities of students, interns, residents, and fellows.
Include the number taught, months taught, etc.
Other Teaching Activity
In addition to formal preceptorship of OSU medical students, interns or residents, what other types of teaching activity have you performed in the past year?
_____ Grand Rounds Presentations at OSU
_____ Subspecialty Conferences at OSU
_____ Invited House Staff Conferences
_____ Resident Morning Report
_____ Leading MED III/IV Discussion Groups
_____ Introduction to Clinical Medicine Course for OSU Medical Students
_____ Physical Diagnosis Course of OSU Medical Students
_____ Preceptorship of Elective Medical Student Rotations (Please specify.)
Other (Please specify.)

Other Instructional Activities:
Please respond to the following questions about your OSU instructional activities.
Do you give CME lectures to other physicians? If so, please list topics, dates and places.
Have you developed new teaching methods or materials? Please give details.
What contributions have you made to course or curriculum development?
What other instructional activities have you engaged in on behalf of our educational programs at Ohio State?

Other Scholarly Activity
In the space below, please summarize other scholarly activity in which you are involved.
Please be very specific. Include publications, grants and research activities, local, regional and national presentations, etc. Use a separate, additional sheet if necessary.
Service Activities
Please indicate those service activities in which you participated during the past academic year. Include advising and counseling activities and service on hospital, departmental, college and university committees. List any local, regional or national appointments.
Signature of Faculty Member Completing Form:
Signature of Medical Education Director at
Affiliated Hospital:
__________________________
__________________________
Signature of OSU Division Chief:
Signature of OSU Department Chairman:
__________________________
__________________________
Thank you for taking the time to complete this information. Please return the completed form to:
E. Christopher Ellison, M.D.
Chair, Department of Surgery
The Ohio State University Medical Center
395 W 12 th Ave, Room 692
Columbus OH 43210