Annual Faculty Evaluation:
Academic Goals and Activities
Name: / Calendar Year:Academic Rank & Years at Rank:
Track:
Department/and Division:
Distribution of Effort:Indicate percent of your time spent on the following activities. (Total = 100%)
% Research/Scholarship / % Clinical% Teaching/Training / % Administrative
% Service / % Other (specify)
Training and Compliance:If applicable to work done during the calendar year, please indicate where compliance is current.
Compliance area / Yes / No / N/AThe Responsible Conduct of Research
Radiation Safety
Human Subjects Research
Intellectual Property
Risk Management
Animal Care and Use
Use and Handling of Hazardous Materials
Conflict of Interest
Education:List the courses and other education activities you have been involved in during the calendar year.(You may attach additional pages)
Course: Number/Title / Time Commitment / RoleOther:All other education-related activities you have been involved in during thecalendar year.
Clinical:List clinical activities you have been involved in during the calendar year.(You may attach additional pages)
Description / Time CommitmentMentoring:List mentoring responsibilities you have been involved in during the calendar year.Please note if you need additional skills to mentor effectively. You may include additional information using the table template found HERE.
Your Role / Mentee Role (students, fellows, faculty) / Number of Mentees / Additional Skills NeededAdministration:List administrative duties you have within the Department/Division and University during the calendar year.(You may attach additional pages)
Description / Time CommitmentPublications:List all manuscripts published orin pressfromJanuary 1– December 31. Separate out peer reviewed, original research articles from reviews, book chapters, and books. Bold name in author list.
Manuscripts:List all manuscripts submitted from January 1 – December 31 (list only first submission). Please include: Title, Author List, Name of Journal, Date of submission. Bold name in author list. Please indicate if first or last author is a trainee at any level.
Invited Talks:List invitedtalksfromJanuary 1– December 31.
Activities:List current activities in professional National/International organizations from January 1– December 31(e.g., study sections, editorial boards, advisory committees).
Research Support:List all current grant support.(You may attach additional pages)
Funding Source / Role(i.e.: PI, Co-PI, Collaborator) / Award Period
(dates) / Annual Direct Cost / Your Percent
Funded Salary Effort
List all grants submitted and planned. (You may attach additional pages)
Funding Source / Role(i.e.: PI, Co-PI, Collaborator) / Award Period
(dates) / Annual Direct Cost / Your Percent
Funded Salary Effort
Faculty Achievement:List any specific achievements this calendar year not noted above.
Facultyand departmental issues:List professional issues important for your academic development
(e.g., need for departmental resources, faculty mentoring or other support) and issues that are important for the function of the department/division.
Well-being Goals and Activities: List personal/well-being issues important for your academic development. If you wish to explain impediments to your past productivity, you may include a description of factors such as family care responsibilities, illness, disability, and active military service.
Academic Goals: List your Goals for the coming year.
If applicable, please indicate by percentage of time,anychange you would like to make to the academic activities listed on page one (1).
Increase time / % (specify)Decrease time / % (specify)
Note: Any changes noted above will be taken into consideration but are not guaranteed.
Other (Please specify)
[USE THIS SPACE IF YOU WISH TO INCLUDE SIGNATURE BLOCKS – THEY ARE NOT REQUIRED]
December 20161