HWCOM Appointment, Promotion and Tenure Nomination Form Date:
Complete Section 1: Name of Candidate: ______Action: Faculty Type: *If paid, select appointment type: *If paid, select Non-Tenure Track: Department Name: Rank You Propose: *If “Yes” to question 3 below, proposed rank should be “Adjunct” *Refer to the HWCOM Faculty Bylaws for qualifications
Complete Section 2 1. Does the individual qualify as an Affiliate Faculty? ☐Yes, list site ______☐ No Refer to page 3 – cannot leave blank 2. Does the individual have a voluntary appointment at another academic institution? ☐Yes ☐ No If yes, please indicate the university, department and rank (include those employed in a different college here at FIU): ______3. Does the individual have a regular appointment at another academic institution? ☐Yes ☐ No If yes, please indicate the university, department and rank (include those employed in a different college here at FIU): ______4. Please select which HWCOM Program this individual will be participating in: 5. Please select Primary Role (cannot leave blank): 6. Please select Secondary Role (if applicable): 7. Other interest in HWCOM missions: 8. Gold Humanism Honor Society member: 9. Alpha Omega Alpha (AOA) member: 10. Is the faculty actively involved in a course? 11. Expected responsibilities/justification for appointment. ______Complete Section 3 (Secondary Appointments ONLY): Primary Business Unit: ______Primary Department name: ______Primary Business Unit Chair Name: ______Primary Business Unit Chair Signature: ______
Complete Section 4 Please fill in the blanks (if not applicable, place N/A): ☐ State of Florida professional license # ______☐ Num. of Publications______☐ American Board of______☐ Write email address ______
Approval Section 5
______Chair, Department of
______Yolangel Hernandez-Suarez, MD Associate Dean of Clinical and Community Affairs *Incomplete forms will be sent back to the Department for completion. Updated August 2019
Community-Based Faculty Appointment Information Form
Personal Information
Date:
Full Name: First M.I. Last
Address: Street Address Apartment/Unit #
City State ZIP Code
Home Phone: Cell Phone:
Email Address:
Birth Date (MM/DD/YY): Marital Status:
Country of Birth: Citizenship:
Gender: Ethnic Group: ☐ American Indian/Alaskan Native ☐ Female ☐ Asian ☐ Male ☐ Black/African American
☐ Hispanic
☐ Native Hawaiian/Pacific islander ☐ White ☐ I decline to provide my self-identification
Highest Academic Date Discipline of Degree Achieved: Completed: Degree:
Specialty: Sub-specialty:
Emergency Contact Information
Full Name: First Last M.I.
Address: Street Address Apartment/Unit #
City State ZIP Code
Primary Phone: Alternate Phone:
Relationship:
Date modified: 05/29/2019
Below is a list of our affiliate hospitals/clinics.
1. Are you or your practice employed by any of the following Hospitals/Clinics listed below? ☐Yes, mark below ☐No 2. Are you or your practice contracted by any of the following Hospitals/Clinics to teach students? ☐Yes, mark below ☐No