The Warren Alpert Medical School of Brown University

The Warren Alpert Medical School of Brown University

Clinical Faculty Review Form

Submit form to Division Director, Hospital Chief, or Department Administrator

Name: Click here to enter text. Initial Year of Appointment: Click here to enter text.

Department: Choose an item. Division/Specialty: Click here to enter text.

Office Address: Click here to enter text.

Office Phone: Click here to enter text. Ext: Click here to enter text. Fax: Click here to enter text.

Email: Click here to enter text.

Hospital affiliation: Choose an item.

Clinical Faculty rank: Choose an item.

Track: Choose an item.

List teaching or service activities below with emphasis on recognized, formal teaching activities relating to Brown medical students, residents and fellows.

Teaching or Service Activity / Level and Number of Learners / Frequency (# of hours per week/month/year) / Additional Information
Inpatient teaching attending / Click here to enter text. / Click here to enter text. / Click here to enter text.
Resident in the office / Click here to enter text. / Click here to enter text. / Click here to enter text.
Resident in the office-on match list but not chosen / Click here to enter text. / Click here to enter text. / Click here to enter text.
Physical diagnosis preceptor / Click here to enter text. / Click here to enter text. / Click here to enter text.
Preceptor, 3rd year student clerkship / Click here to enter text. / Click here to enter text. / Click here to enter text.
Outpatient clinic preceptor / Click here to enter text. / Click here to enter text. / Click here to enter text.
Subspecialty or GIM service attending / Click here to enter text. / Click here to enter text. / Click here to enter text.
Pathophysiology course preceptor / Click here to enter text. / Click here to enter text. / Click here to enter text.
The Doctoring Program / Click here to enter text. / Click here to enter text. / Click here to enter text.

List teaching activities on the grid below with emphasis on recognized, formal teaching activities relating to Brown medical students, residents and fellows.

Teaching or Service Activity / Level and Number of Learners / Frequency (# of hours per week/month/year) / Additional Information
Bedside teaching (documented) / Click here to enter text. / Click here to enter text. / Click here to enter text.
Resident Advisor / Click here to enter text. / Click here to enter text. / Click here to enter text.
Student advisor in PLME or medical school / Click here to enter text. / Click here to enter text. / Click here to enter text.
Tutorial preceptor for students/residents and/or fellows / Click here to enter text. / Click here to enter text. / Click here to enter text.
Morning report participant / Click here to enter text. / Click here to enter text. / Click here to enter text.
Grand Rounds, M&M Conference,
subspecialty conference presenter / Click here to enter text. / Click here to enter text. / Click here to enter text.
Journal Club Presenter / Click here to enter text. / Click here to enter text. / Click here to enter text.
Book or journal article publications / Click here to enter text. / Click here to enter text. / Click here to enter text.
Hospital/University committee member or chair / Click here to enter text. / Click here to enter text. / Click here to enter text.
Professional organization leadership / Click here to enter text. / Click here to enter text. / Click here to enter text.
Participation in subspecialty conferences / Click here to enter text. / Click here to enter text. / Click here to enter text.
Office Research/Other / Click here to enter text. / Click here to enter text. / Click here to enter text.
Total Number of Hours Documented: / Click here to enter text. / Click here to enter text. / Click here to enter text.

Additional information relevant to the appointment/reappointment process may be included on a separate page.

Teaching evaluations are required for reappointment and can be obtained through Oasis and E*Value. Contact course facilitator for assistance.

Updated CV Enclosed: ☐ Teaching Evaluations enclosed: ☐

Click here to enter a date.

Faculty Signature Date

Click here to enter a date.

Division Director/Hospital Chief Signature Date

Brown University Annual Clinical Faculty ReviewPage 1