A. MEDICAL SCHOOL COURSES (USE 1 PAGE PER COURSE OR ACTIVITY)

COURSE NAME AND NUMBER:

Year Taught
# of Students
Role in Course / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other
Required or Elective / Required
Elective / Required
Elective / Required
Elective / Required
Elective / Required
Elective
Did You Develop Instructional Materials?
What?
Teaching Hours/Year / Lecture:
Small Group:
Other: / Lecture:
Small Group:
Other: / Lecture:
Small Group:
Other: / Lecture:
Small Group:
Other: / Lecture:
Small Group:
Other:
Teaching Awards

B. UNDERGRADUATE AND GRADUATESCHOOL COURSES (USE 1 PAGE PER COURSE OR ACTIVITY)

COURSE NAME AND NUMBER:

Year Taught
# of Students
Role in Course / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other / Director
Lecturer
Senior Leader
Other
Required or Elective / Required
Elective / Required
Elective / Required
Elective / Required
Elective / Required
Elective
Did You Develop Instructional Materials?
What?
Teaching Hours/Year / Lecture:
Small Group:
Other: / Lecture:
Small Group:
Other: / Lecture:
Small Group: Other: / Lecture:
Small Group:
Other: / Lecture:
Small Group:
Other:
Teaching Awards

C. RESIDENCY/FELLOWSHIP/PREDOCTORAL PSYCHOLOGY INTERNSHIP/POSTDOCTORAL PSYCHOLOGY FELLOWSHIP (Example: Program Director, Elective Director, Attending, Journal Club Organizer, Psychology Track Coordinator)

TRAINING PROGRAM AND DEPARTMENT:

Year Taught
# of Trainees/Year
Role in Training Program / Program Director
Elective Director
Lecturer
Senior Leader
Attending
Journal Club Coord.
Psyc. Track Coord.
Other / Program Director
Elective Director
Lecturer
Senior Leader
Attending
Journal Club Coord.
Psyc. Track Coord.
Other / Program Director
Elective Director
Lecturer
Senior Leader
Attending
Journal Club Coord.
Psyc. Track Coord.
Other / Program Director
Elective Director
Lecturer
Senior Leader
Attending
Journal Club Coord.
Psyc. Track Coord.
Other
Required or Elective / Required
Elective / Required
Elective / Required
Elective / Required
Elective
Did You Develop Instructional Materials?
What?
Teaching Hours / Lecture:
Small Group:
Other / Lecture
Small Group:
Other: / Lecture
Small Group
Other: / Lecture:
Small Group:
Other:
Teaching Awards

D. CLINICAL EDUCATION (This includes formal teaching roles only. Example: Attending Physician, Assigned Precepting in Ambulatory Setting or OR)

Role in Training Program
Year
Site
Contact Student or House Staff Hours/Year
# Trainees Per Year
Teaching Awards

E. CLINICAL CONFERENCES (Example: Teaching at House Staff Conferences, M & M Residents’ Report, etc.)

Role in Training Program
Year
Site
Contact Student or House Staff Hours/Year
# Trainees Per Year
Teaching Awards

F. CONTINUING MEDICAL EDUCATION (Example: Presentations at Grand Grounds or Courses offering CME)

Program
Date
Place
Sponsor
Role: Organizer or Lecturer / Organizer
Lecturer
Other / Organizer
Lecturer
Other / Organizer
Lecturer
Other / Organizer
Lecturer
Other
Number of Teaching Hours
Teaching Awards

G. RESEARCH SUPERVISION.

Provide requested information on medical students, under-graduates and graduate students, postdoctoral fellows, residents, or any others who have been supervised since the last promotion or appointment to the current rank.

Name of Trainee
Status/Institution if Other than Brown
Dates
# of Publications Resulting From this Work (Please List)
Current Position of Trainee if Known
Nature of Supervision/Extra-Mural Funding
Teaching Awards

H. MENTORING ACTIVITIES (Faculty, Students, House Staff)

Name of Mentee
Dates
Status of Mentee
Mentoring Role
Current Position of Mentee (If Known)
Mentoring Awards or Funded External Support (eg K or NRSA)

I. NATIONAL/REGIONAL TEACHING AWARDS

Award
Date
Awarded By: