APPLICATION FORMS FOR PROMOTION OF
FULL-TIME NON-REGULAR PHYSICIAN FACULTY[1]
2011-2012 PROMOTION CYCLE
UNIVERSITY OF MISSOURI – KANSAS CITY
SCHOOL OF MEDICINE
UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF MEDICINE
APPLICATION FORM FOR PHYSICIAN FACULTY PROMOTION
COVERSHEET AND CHECKLIST
Name: Degree (M.D., D.O.):
Last First MI
Department: Subspecialty:
Institution/Hospital:
Current Faculty Rank: Date of Current Appointment: ____/____/____
Years in Current Faculty Rank as of 07/01/2012 Years
Requested Faculty Rank: Effective Date of Promotion: 07/01/2012
CHECKLIST:
The following items must be submitted with each application. Incomplete applications will be returned to the faculty member and may delay the evaluation process. Please place documents in the following order:
q Personal Information (Part I)
q Personal Information Sheet
q Faculty Self Assessment (not to exceed two single-spaced, typewritten pages.)
q Current CV
q Scholarly Activities Sheets (Part I)
q Teaching w/Supporting Materials (additional materials which clarify/support scholarly activities).
q Service w/Supporting Materials (additional materials which clarify/support scholarly activities).
q Clinical Practice w/Supporting Materials (additional materials which clarify/support scholarly activities).
q Research w/Supporting Materials (additional materials which clarify/support scholarly activities).
q Three (3) Reprints of Publications which best represent applicant’s work (behind Research)
q List of External Scholars (a minimum of five (5) External Scholars in the applicant’s clinical field who are not affiliated with UMKC SOM).
The faculty member will submit the above completed documents to the Department’s Promotion Committee, if there is one, the Department Chair and the Associate Dean of the affiliated institution for their review.
q Department Promotion Committee, if there is one (Part II)
q Department Chair Report (Part II)
q Associate Dean’s Report (Part II)
The Department’s Promotion Committee, if there is one, the Department Chair and Associate Dean are responsible for reviewing the entire application to ensure that the faculty member meets the basic criteria for his/her requested promotion. If the faculty member is qualified, the Department’s Promotion Committee, if there is one, the Department Chair and Associate Dean will attach their review to the application and forward the entire packet to UMKC SOM Faculty Affairs Department.
Each faculty member is responsible for submitting the six copies of Part I, six copies of publications and two copies of the External Scholars List to the UMKC SOM Office of Faculty Affairs by October 1, 2011, along with a digital copy (CD or flashdrive) of faculty member’s portfolio and External Scholars List (in Word format), a copy of all teaching evaluations in pdf format (not limited to UMKC evaluations, can be from other schools) and a copy of publications in pdf format.
UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF MEDICINE
APPLICATION FORM FOR PHYSICIAN FACULTY PROMOTION
PERSONAL INFORMATION
PART I
Name: Degree (M.D., D.O.):
Last First MI
Department: Subspecialty:
Institution/Hospital:
Current Faculty Rank: Date of Current Appointment: ____/____/_____
Years in Current Faculty Rank as of 07/01/2012: Years
Requested Faculty Rank: Effective Promotion Date: 07/01/2012
Indicate at least 3 Scholarly Activities: Teaching (Required) Service (Required)
Clinical Practice OR Research
Please Note: You may select all 4 Scholarly Activities.
1. List all degrees attained after high school, citing institutions from which you received the degrees and dates of the degrees. Indicate if you received any special recognition with your degrees.
2. List internships, residencies, fellowships, and/or postdoctoral training citing institutions, city and state/foreign country from which you received your postgraduate training, what specialty areas of training and dates of your postgraduate training.
3. List professional certifications, licensures and any special/significant recognition connected with your educational background.
4. List areas of specialization(s).
5. Indicate any other pertinent educational experience, where and dates.
UNIVERSITY OF MISSOURI-KANSAS CITY SCHOOL OF MEDICINE
APPLICATION FORM FOR PHYSICIAN FACULTY PROMOTION
FACULTY SELF ASSESSMENT
PART I
INSTRUCTION
List any evidence you wish which reflects your own professional and personal growth and effectiveness in the required scholarly areas of teaching and service. Also please discuss either clinical practice and/or research; and of course, you have the option to discuss all four (4) scholarly areas. You should describe your accomplishments in each of the three (3) or four (4) scholarly areas by correlating with the examples used in the Levels of Intensity (1, 2 and/or 3) depicted in Appendix C of the Guidelines.
NARRATIVE
Candidate’s Signature
Print Candidate’s Name
Date
SCHOLARLY ACTIVITIES PART I TEACHING
NAME:
Completion of Scholarly Activities—Teaching is required for consideration to allow the SOM Faculty Appointment and Promotion Committee to assess the merit of each listed activity since affiliation with UMKC or last promotion. Where applicable, brief narrative descriptions of the teaching activity should be included. The applicant may attach additional pages if necessary. Entries on additional pages should be grouped by the categories listed below with headings which provide clear reference to these categories.
1. FACULTY RANK: Beginning with present position and in reverse chronological order, list all faculty positions and ranks held, giving dates and institutions.
2. MEDICAL STUDENT TEACHING: List all courses in which you taught since your affiliation with UMKC or your last promotion. Provide the official university course title/number, students involved (year 1, 2, etc.), class enrollment number, date(s) of your involvement and a brief narrative of your participation (content of your teaching/presentations). Begin list with most recent courses and continue in reverse chronological order. Please provide all Student Teaching Evaluations since your affiliation with UMKC or last promotion.
SCHOLARLY ACTIVITIES PART I TEACHING
NAME:
3. CLINICAL TEACHING: Beginning with the most recent and then in reverse chronological order, list all clinical teaching activities in which you participated. These activities may include both formal and informal lectures, bedside teaching rounds and grand rounds, but must involve students, residents, fellows and/or faculty. Provide date(s), location (hospital/institution) and clinical service in which these activities occurred. Narrative descriptions of each activity (see above) are particularly relevant to this category of scholarly activity. Please provide all Resident, Fellows and/or Faculty Teaching Evaluations since your affiliation with UMKC or last promotion.
4. HONORS/AWARDS: In reverse chronological order, beginning with the most recent, list those awards or honors recognition received for teaching activities. Please list the name of the award, awarding agency/department, what the award recognizes and the date it was received. This list should be limited to those awards/honors received since your affiliation with UMKC or last promotion.
SCHOLARLY ACTIVITIES PART I TEACHING
NAME:
5. OTHER TEACHING: In this section, the faculty member may list other teaching activities since affiliated with UMKC or last promotion. The applicant is referred to Appendix B, Guidelines for Promotion of SOM Full-Time Non-Regular (Non-Tenure) Physician Faculty for suggestions on the types of other or innovative activities which may be included. These suggestions are not all-inclusive however. Faculty members who have other unique or innovative teaching activities are encouraged to describe those in this section. Each activity must be listed by title, date(s) of activity, location and with a narrative description as mentioned above. Candidates may attach additional documentation (e.g., lecture notes, publication reprints) which elucidate the faculty member’s activities for up to two (2) of these activities.
SCHOLARLY ACTIVITIES PART I SERVICE
NAME:
Completion of Scholarly Activities—Service is required for consideration for faculty promotion. The following areas should be described with sufficient detail to allow the SOM Faculty Appointment and Promotion Committee to assess the merit of each listed activity. All activities described below should occur since the applicant’s affiliation with UMKC or applicant’s last promotion. Where applicable, brief narrative descriptions of the service activity and the faculty member’s contribution should be included. The applicant may attach additional pages as necessary. Entries on additional pages should be grouped by the categories listed below with headings which provide clear reference to these categories.
1. APPOINTMENTS: Beginning with present position and in reverse chronological order since affiliated with UMKC or last promotion, list all offices or appointments (Chairmanships, Dean, Associate Dean, etc.). Give dates of appointment(s) and institutions or hospitals where those appointments are held.
2. COMMITTEES: List all UMKC, UMKC SOM and affiliated hospital committees in which you are a member. If you hold a specific office on the committee (e.g. Chair), include that position in the listing. For non-UMKC SOM committees please provide a brief narrative description of the committee’s function(s) and your contributions. Begin this list with most recent committee activities and continue in reverse chronological order, providing dates of service and location(s) for each item since affiliated with UMKC or last promotion.
SCHOLARLY ACTIVITIES PART I SERVICE
NAME:
3. PROFESSIONAL ORGANIZATIONS: Beginning with national/international and proceeding through regional and local levels, list all professional organizations or societies in which you are a member since affiliated with UMKC or last promotion. If you hold an appointive or elective office in one of these organizations, indicate what office you hold and for what period of time. For those organizations that have a specific focus or are specialty/subspecialty oriented, a brief narrative description of the organization and your involvement would facilitate the evaluation process. If membership is selective (e.g. performance-based), you may want to briefly describe the selection criteria.
4. COMMUNITY SERVICE: In reverse chronological order for dates of service, list any community organizations in which you are a member or participant since affiliated with UMKC or last promotion. These need not necessarily be medically related. Brief narrative descriptions may be necessary to clarify your role and contributions to these organizations. If you hold elected or appointed positions within these service groups or the community, identify those positions and briefly describe your role.
SCHOLARLY ACTIVITIES PART I SERVICE
NAME:
5. HONORS/AWARDS: In reverse chronological order, beginning with the most recent, list those awards or honors recognition received for public, professional or institutional service activities. Please list the name of the award, awarding agency/department, what the award recognizes and the date it was received. This list should be limited to those awards/honors received since affiliated with UMKC or last promotion.
6. OTHER SERVICE: In this section, the faculty member may list other service activities which may not be appropriate for one of the above categories. The applicant is referred to Appendix B, Guidelines for Promotion of SOM Full-Time Non-Regular (Non-Tenure) Physician Faculty for suggestions on the types of other or innovative activities which may be included since affiliated with UMKC or last promotion. These suggestions are not all-inclusive however. Faculty members who have other unique or innovative teaching activities are encouraged to describe those in this section. Each activity must be listed by title, date(s) of activity, location and with a narrative description as mentioned above. Candidates may attach additional documentation (e.g. media and public interest articles) which elucidate the faculty member’s activities for up to two (2) of these activities.
SCHOLARLY ACTIVITIES PART I CLINICAL PRACTICE
NAME:
Completion of Scholarly Activities—Clinical Practice is optional for consideration for faculty promotion. Applicants must demonstrate excellence in three (3) of the four (4) recognized areas of scholarly activity. Teaching and Service are mandatory areas for evaluation. Clinical Practice and Research are optional areas. Candidates may elect not to submit data for one of the optional areas, or they may submit information in all four (4) areas and allow the SOM Faculty Appointment and Promotion Committee to independently consider their strengths in those areas. The following areas should be described with sufficient detail to allow the Committee to assess the merit of each listed activity. All activities described below should occur since the applicant’s affiliation with UMKC or applicant’s last promotion. Where applicable, brief narrative descriptions of the clinical practice activity should be included.
1. PRACTICE: Identify the type of clinical practice in which you are engaged: private practice, solo or group, hospital-based or university based. Briefly describe the nature of your practice and the types of patients you see. If not in full-time practice, please describe your clinical responsibilities and the frequency/duration of time in which they occur.
2. TEACHING: If you have students/residents/fellows who spend time in your practice/clinic, please describe their role in your practice and the frequency with which they attend. If you teach these trainees clinical practice issues (beyond diagnosis and treatment), please describe those activities (e.g. practice management).
SCHOLARLY ACTIVITIES PART I CLINICAL PRACTICE
NAME:
3. INNOVATION: Describe the recent therapeutic/diagnostic changes that have occurred in your specialty or subspecialty. Identify how those activities have been incorporated into your practice and how they have impacted patient care. If you provide clinical care for a specific subset of patients (within your specialty/subspecialty), describe those efforts and the unique innovative clinical aspects of this practice. If your practice participates in phase III or post-marketing clinical trials, please identify those trials by name and describe your involvement.
4. HONORS AND AWARDS: In reverse chronological order, beginning with the most recent, please list any honors or awards you have received for clinical practice and/or patient care. List awards by title, date of award and location. A brief description of the award and what it recognizes should be included. Only provide the honors/awards which were bestowed upon you since your affiliation with UMKC or since your last promotion.
SCHOLARLY ACTIVITIES PART I CLINICAL PRACTICE
NAME:
5. CONTINUING MEDICAL EDUCATION: In reverse chronological order, beginning with the most recent, list hours of CME credit per year in which you have participated since your affiliation with UMKC or since your last promotion. Please identify if you were a presenter.
6. PRESENTATIONS AND PUBLICATIONS: In reverse chronological order list all publications and/or presentations relevant to your clinical practice since affiliated with UMKC or your last promotion. These activities may include visiting lectureships, consultation arrangements, books/book chapters and clinical reviews. Published manuscripts should be cited in standard bibliographic format (authors, title, journal, volume, page(s) and date. Presentations should include the title of the presentation, date, who presented to and where presented.
SCHOLARLY ACTIVITIES PART I CLINICAL PRACTICE
NAME:
7. OTHER CLINICAL PRACTICE: In this section, the faculty member may list other innovative or scholarly clinical practice activities. The applicant is referred to Appendix B, Guidelines for Promotion of SOM Full-Time Non-Regular (Non-Tenure) Physician Faculty for suggestions on the types of other or innovative activities which may be included. These suggestions are not all-inclusive however. Faculty members who have other unique or innovative teaching activities are encouraged to describe those in this section. Each activity must be listed by title, date(s) or activity, location and with a narrative description as mentioned above. Candidates may attach additional documentation which clarifies the faculty member’s activities for up to two (2) of these activities.