Date of preparation
NAME (with degrees)
Business Address:
Business Phone:
Email:
EDUCATION
(Include degree, award date, Institution and discipline)
College
Medical School
TRAINING
(Include degree, award date, Institution and discipline)
LICENSURE / CERTIFICATION
ACADEMIC APPOINTMENTS
HOSPITAL APPOINTMENTS
OTHER EMPLOYMENT (optional)
HONORS AND AWARDS
A. Elected Society Memberships
B. International/National/Regional
C. University
INSTITUTIONAL SERVICE (Committees, Councils, Task Forces)
A. University
B. School
C. Department
D. Hospital
COMMUNITY / PUBLIC SERVICE
PARTICIPATION IN PROFESSIONAL SOCIETIES AND EXTRAMURAL ORGANIZATIONS
A. Professional Society Memberships
B. Leadership and Service (leadership positions held, committee service, etc.)
EDITORIAL AND MANUSCRIPT REVIEW RESPONSIBILITIES
GRANT REVIEW RESPONSIBILITIES
GRANT AWARDS AND CLINICAL TRIALS
A. Current
B. Pending
C. Past
Guidance: For each grant/clinical trial, include your role and the direct costs you received for the award, as in the format below:
Agency:
ID#:
Title:
Principal Investigator:
Role on project: (include if you are not the PI—e.g., Site PI, Co-investigator, etc.)
Percent effort:
Direct costs per year:
Total costs for project period:
Project period:
INVITED LECTURES
A. International/National
B. Regional
C. Local
PUBLICATIONS AND SCHOLARLY WORK
Guidance: When reporting publications/scholarly work, list them in chronological order (earliest to most recent), list all authors in the order they appear on the publication, and put your name in bold font.
A. Peer-reviewed Original Investigations
B. Invited Reviews and Commentaries
C. Books and Book Chapters
D. Peer-Reviewed Educational Materials
E. Case Reports, Letters, Editorials
F. Practice Guidelines, Standards, and Consensus Statements
G. Public Policy and Legislative Testimony
H. Patents
I. Database Deposition
J. Software
K. Abstracts (*denotes presenting author)
Guidance: Put an asterisk beside the presenting author. Make note of any abstracts that received honors or awards.
a. Oral Abstract Presentations
b. Poster Presentations
MEDIA COVERAGE AND APPEARANCES
Guidance: Include news coverage of your work, your appearances in the media (e.g., print, TV, or radio interviews), websites you maintain related to your academic career, and social media involvement for the medical/scientific community (e.g., maintaining a blog, running a Twitter feed, podcasting, etc.)
TEACHING (optional section)
Note: This section is optional because it is duplicative of the Documentation of Teaching Form, which is required for most promotion candidates.
TRAINEES (optional section)
Note: This section is optional because it is duplicative of the Documentation of Teaching Form, which is required for most promotion candidates.