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Academy Member Membership Renewal Application 1 Cover Page Name: Position/Title: Primary School: Double-click to select Department: Campus Address/Office

Location: Campus Campus Telephone: Email: As of today’s date, number of years employed as a LSUHSC faculty

member: Your current faculty rank: Instructor Assistant Professor Associate Professor Professor Is this a tenure-track Yes No appointment? Achieved tenure already? Yes No Not applicable

Year Current Academy Associat Fello Master Teaching Inducted: membership category: e w Teacher Scholar ______Check the teaching/education domains for which you have included information in this membership renewal application: Teaching Curriculum Advising and Leadership and Educational Development, Mentoring Service Research Instructional Design & Assessment of Student Learning

I attest that the content of this membership renewal application is accurate and the result of my own work.

______Academy Member Signature Date Submitted

Composition of the Academy Membership Renewal Application

Your Academy membership renewal application includes the following components:

1. This cover page 2. Narrative report: Quantity, quality and engagement in teaching and education (see next page for template) 3. Appendix that include the following required items: a. Teaching Record (template included as last page of this document) b. Curriculum Vita c. Annual Academy activity reports d. List and descriptions of Academy leadership and service contributions

Please continue on the next page to complete the Narrative Report and include Appendix items. Double click here to open, then highlight text to replace with first name, last name, suffix 2

Narrative Report: Quantity, Quality, and Engagement in Teaching and Education

General Directions: Complete the table below and report only teaching and education activities and achievements since your induction into the Academy. Some prompts are included in the cells and footnotes to help you decide what information to include. Replace the highlighted text in each cell with your own information. Include relevant descriptions and forms of evidence for each educational domain that you checked on the cover page. Be concise, but complete enough for reviewers to understand your involvement and achievements. When events, presentations, publications in teaching/education are reported, please be sure to provide the complete reference/citation in the Evidence section for Engagement. For evidence that is already in your CV, cite reference and its location in the CV (e.g., page and item number(s)).

Narrative/Description Evidence Quantity Brief description of scope and Complete and reference the Teaching Record (Roles and examples of roles and activities (next page); List other entries that provide Activities) evidence of quantity

Quality Describe the specific aspects of List here the specific results or (Effectiveness and effectiveness and/or excellence you outcomes/products that provide evidence of Excellence) have achieved/sought to achieve the quality features you described to the left. (e.g., increased student ratings of teaching, learning outcomes that result from a new curriculum) Engagement Provide an overview description of List collaborative projects, Academy events, (e.g., how you have collaborated and faculty development workshops, publication Collaboration; participate with others in teaching and presentation citations from your CV or you Academy and education and engaged in the can attach your CV and reference exactly 1 participation , community of educators (please see where in your CV the evidence is located (e.g., Scholarly footnotes) page #, citation #). For Academy-sponsored Approach2, Scholarship3, activities, reference these in the annual Contributions/Impa Academy activities summary reports that are ct) included in the Appendix.

Required Appendix Items

1. Teaching Record - Please complete the template shown on the next page for direct teaching in the most recent five years.

2. Curriculum Vitae – This document can be in any format (e.g., the formation required by your School).

3. Annual Academy Activity Reports – Include a copy of each annual Academy activity report since your induction into the Academy. These reports were sent to you annually as a summary of the specific

1 Academy participation – describe/list Academy workshops, symposia, meetings, projects, teams, etc. in which you participated in the past 12 months. 2 Scholarly approach – includes activities such as drawing from the literature, adopting best practices, building on the work of others to innovate, improve, and/or expand your teaching and education work. 3 Scholarship in teaching and education can include how you have contributed to the educational community (e.g., disseminated the outcomes or products of your scholarly work in teaching and education). Among these activities may be presentation/publication citations, a bulleted list of dissemination activities by date and brief description, list of individuals or other organizations who have benefited from your scholarly work (e.g., peer review and critique, adoption or adaptation of an educational method or enduring material that you have created and disseminated). Double click here to open, then highlight text to replace with first name, last name, suffix

Academy-sponsored activities in which you participated. If you did not keep these reports, please 3 contact Ms. Kelly Nester (504-568-2140, [email protected] to request a duplicate copy. Please keep a copy of these reports for your file and future use.

4. Academy leadership and service contributions – Please provide a list of your leadership roles and service contributions to the Academy since your induction (e.g., membership on a team, peer review panel, Advisory Group, Executive Council) and provide a brief description of the period of service and your specific contributions for each. Double click here to open, then highlight text to replace with first name, last name, suffix 4 TEACHING RECORD

Name: School: Date:

Page: of

Please complete for only the most recently completed academic year (i.e., July 2009 – June 2010). Add rows to the table, as needed.

Yea Course Title Cours Hour Number of Learner Teaching Method(s)9 r4 e5 s6 Learners7 Level8 1 2 3 4 5 6 7 8 9 10 11 R E 12

4Please indicate the academic year in which each teaching activity occurred (e.g., 2007-2008, 2009-2010, etc.). Include teaching activities since your induction into the Academy and no more than the most recent five years at LSUHSC-NO. 5R=Required/Core Curriculum Course; E=Elective Course 6Number of hours involved in direct teaching with learners 7Number of learners enrolled/participating in the course/educational program 8Write in each cell the code(s) that apply for the course (Modify key to reflect appropriate learner groups): Y1, Y2, Y3, Y4, G = Ph.D./Graduate, PGY1, PGY2, PGY3, F = Fellow, FD = Faculty Development, C = Continuing Education 9Circle all numerical codes that apply using the following key (Modify the key to reflect relevant teaching methods for your particular situation): 1= Lecture; 2 = Lecture/Demonstration; 3 = Laboratory; 4 = Small Group/Case-Based; 5 = Small Group/Discussion; 6 = Small Group/Seminar; 7 = Hospital/Inpatient/Bedside Rounds; 8 = Hospital/Clinic; 9 = Community/Clinic; 10 = One-to-one, Laboratory/Research Preceptor 11 = One-to-one, Clinical Preceptor; 12 = Distance Learning