Application Form for Clinical Faculty at the College of Medicine, Qatar University

Application Form for Clinical Faculty at
the College of Medicine, Qatar University

Date of preparation:

A. General Information

Provide your full name as it appears in your Passport or Qatar ID

(1) Personal Data:

Name:
Office Address:
Office telephone:
Mobile phone:
Name of Department:
Name of Hospital:
Email:
Citizenship:
Birth date:
Marital status:

(2) Current Institutional Responsibilities

The Four Categories – Teaching, Research, Clinical Care and Administration – are those areas of service upon which the criteria for all academic faculty position and promotions are based on. Calculate the time/effort in each of the four (4) areas based on a 35-hour week and convert to percent.
Institutional Responsibility / Effort in percent (%)
Teaching
Clinical Care
Administration
Research
Total
/ 100%

B. Qualification

(1) Degrees

Only academic institutions (Colleges, Universities), confer academic degrees;
Degree:
Provide the complete name of the degree and it’s abbreviation e.g. Bachelor in Medicine and Surgery (MBBS); Medical Doctorate (MD)
Academic Institution Name and Location:
Please enter the name and location (City and Country) of each academic institution that conferred your degree
Degree (Full name of degree and Abbreviation) / Institution Name and Location
(City and Country) / Dates attended / Year Awarded / Upload

(2) Board Certification, Licensure

(a) Licensure

Name of Licensing Body / Country of Issue / Specialty / Date of Certification / Upload

(b) Specialty Certifying Body

Name of Licensing Body / Country of Issue / Specialty / Date of Certification / Upload

C. Clinical Experience

(1) Clinical Experience in Years (only one option to be chosen):

(a) Two to three years

(b) Three to five years

(d) Seven to ten years

(e) More than ten years

(2) Postgraduate Training (include Residency and Fellowship Programs)

Include all training positions from first position to last after graduating from Medical College.
Title (e.g. Intern, Resident, Fellow – including Specialty)
Name of Hospital/ Institution and Location (City and Country)
Title / Specialty / Institution Name and Location
(City and Country) / Dates held / Upload

(3) Hospital Positions

From first to last position:
· Title of Position and Specialty
· Hospital/ Institution Name and Location
· Dates held (begin and end)
Title / Specialty / Institution Name and Location
(City and Country) / Dates held / Upload

(4) Institutional Responsibilities: Clinical Care

Give details of your current clinical responsibilities and describe a typical week/month job plan;
Provide information upon your area of expertise, number of patients, or procedures performed
Name of Institution and Location (City and Country) / Position / Activity / Dates held

(5) Institutional Responsibilities: Administrative Duties

Include current administrative duties e.g. Medical Director, Chair of Department, Head of Section (Division), Committee Member, Program Director, Include dates held in Administrative Position
Name of Institution and Location (City and Country) / Position / Activity / Dates held

D. Teaching Experience:

(1) Teaching Experience

In terms of years of teaching experience with medical and/or health science students and/or postgraduate students

(a) Less than one year

(b) One to three years

(d) Five to eight years

(e) More than eight years

(2) Teaching Activities

List the teaching you have done and are currently doing e.g.
· Role in course development and didactic teaching (Lectures, Workshops, Courses for Medical Students, Residents, Fellows
· Role as clinical teacher to Medical Students, Residents, Fellows
· Enumerate all educational activities such as lectures, small groups, rounds, journal clubs in which you are involved
· Include the name of institution where teaching occurred.
Name of Institution and Location (City and Country) / Teaching Activities / Dates held

(3) Academic Positions

List Academic positions held at academic institutions (University, College, Institute)
· Title of position e.g. Instructor, Assistant Professor, Associate Professor, Professor
· Department (include full name of Department and section)
· Institution Name and Location
· Dates Held
Title / Department / Institution name and location / Dates held

E. Research Experience

(1) H-Index:

(2) Research Contribution

Number of published papers in peer-reviewed journals indexed in PubMed

(a) Less than three papers

(b) Three to four papers

(d) Twelve to fifteen papers

(e) More than fifteen papers

(3) Research Activities

Provide a short description of your career in Research and include your significant research accomplishment
Description of Research / Date/s

(4) Research support

Include all funded research , active clinical trials, pending/submitted grant applications and past research support
Source / Amount / Duration of Support
Name of Principal Investigator
Your role in the project / Percent Effort (%)
Research Title
Source / Amount / Duration of Support
Name of Principal Investigator
Your role in the project / Percent Effort (%)
Research Title
Source / Amount / Duration of Support
Name of Principal Investigator
Your role in the project / Percent Effort (%)
Research Title

F. Reputation

(1) Professional Membership (Medical and Scientific Societies)

State your role e.g. Member , Member of Board, Leadership Position e.g. Chairman
Name of Organization and Location (City and Country) / Role / Involvement

(2) Honors and Awards

Examples: Student Award, Scholarship, Resident/ Fellowship Award, Teacher Award, Research Awards
Name of Award / Awarded By / Date Awarded

(3) Extramural Professional Responsibilities

This section demonstrates academic and service engagement outside the site and reputation, local, regional and international. This includes:
· Journal reviewer, grant review
· Invited Lecturer (10 most recent)
· CME/CPD Lecturer/Facilitator (10 most recent)
· Visiting Internship, Conference, Organizer, Keynote Speaker, Community and Voluntary Service
Name of Institution/ Event / Description / Date/s

G. BIBLIOGRAPHY

List entries in chronological order, number entries, and use BOLD type for your name so that it is clear to the reviewer. Entries should follow the New England Journal of Medicine format, listing all authors, complete titles and inclusive pagination;
e.g., Doe J. Ford A, Smith J. Measuring the activities of daily living. N England J Med 1994; 331:778-84).

(1) Articles in Professional Peer-Reviewed Journals (Original Research)

· List only articles that have been published or are in press
· Do not list submitted or articles under review
· Entries should follow the New England Journal of Medicine Format
Title / Upload

(2) Books, book chapter, Editor

e.g. List books, book chapter, review, editorials, comment, case studies, letters invited publication in non-peer reviewed journal
Title / Upload

(3) Abstracts (List 10 best)

e.g. List books, book chapter, review, editorials, comment, case studies, letters invited publication in non-peer reviewed journal
Title / Upload

(4) Presentations other than invited Lectures

e.g. List books, book chapter, review, editorials, comment, case studies, letters invited publication in non-peer reviewed journal
Title / Upload