<p> Application Form for Clinical Faculty at the College of Medicine, Qatar University</p><p>Date of preparation:</p><p>GENERAL INFORMATION </p><p>Provide your full name as it appears in your Passport or Qatar ID </p><p>PERSONAL DATA: </p><p>Name: Office Address: Office telephone: Mobile phone: Name of Department: Name of Hospital: Email: Citizenship: Birth date: Marital status:</p><p>CURRENT INSTITUTIONAL RESPONSIBILITIES </p><p>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.</p><p>Institutional Responsibility Effort in percent (%) Teaching</p><p>Clinical Care</p><p>Administration</p><p>Research</p><p>Total 100%</p><p>1 QUALIFICATION </p><p>DEGREES </p><p>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</p><p>Degree (Full name of degree Institution Name and Location Dates Year Upload and Abbreviation) (City and Country) attended Awarded</p><p>BOARD CERTIFICATION, LICENSURE </p><p>Licensure</p><p>Name of Licensing Body Country of Issue Specialty Date of Certification Upload</p><p>Specialty Certifying Body</p><p>Name of Licensing Body Country of Issue Specialty Date of Certification Upload</p><p>2 CLINICAL EXPERIENCE </p><p>CLINICAL EXPERIENCE IN YEARS (ONLY ONE OPTION TO BE CHOSEN): </p><p>Two to three years Three to five years Five to seven years Seven to ten years More than ten years</p><p>POSTGRADUATE TRAINING (INCLUDE RESIDENCY AND FELLOWSHIP PROGRAMS) </p><p>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)</p><p>Title Specialty Institution Name and Location Dates held Upload (City and Country)</p><p>HOSPITAL POSITIONS </p><p>From first to last position:  Title of Position and Specialty  Hospital/ Institution Name and Location  Dates held (begin and end)</p><p>Title Specialty Institution Name and Location Dates held Upload (City and Country)</p><p>3 INSTITUTIONAL RESPONSIBILITIES: CLINICAL CARE </p><p>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</p><p>Name of Institution and Location Position / Activity Dates held (City and Country)</p><p>INSTITUTIONAL RESPONSIBILITIES: ADMINISTRATIVE DUTIES </p><p>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</p><p>Name of Institution and Location Position / Activity Dates held (City and Country)</p><p>4 TEACHING EXPERIENCE: </p><p>TEACHING EXPERIENCE </p><p>In terms of years of teaching experience with medical and/or health science students and/or postgraduate students Less than one year One to three years Three to five years Five to eight years More than eight years</p><p>TEACHING ACTIVITIES </p><p>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 Teaching Activities Dates held (City and Country)</p><p>ACADEMIC POSITIONS </p><p>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</p><p>Title Department Institution name and location Dates held</p><p>5 6 RESEARCH EXPERIENCE </p><p>H-INDEX: </p><p>RESEARCH CONTRIBUTION </p><p>Number of published papers in peer-reviewed journals indexed in PubMed Less than three papers Three to four papers Four to seven papers Twelve to fifteen papers More than fifteen papers</p><p>RESEARCH ACTIVITIES </p><p>Provide a short description of your career in Research and include your significant research accomplishment</p><p>Description of Research Date/s</p><p>RESEARCH SUPPORT </p><p>Include all funded research , active clinical trials, pending/submitted grant applications and past research support</p><p>Source Amount Duration of Support</p><p>Name of Principal Investigator</p><p>Your role in the project / Percent Effort (%)</p><p>Research Title</p><p>Source Amount Duration of Support</p><p>Name of Principal Investigator</p><p>Your role in the project / Percent Effort (%)</p><p>Research Title</p><p>7 8 Source Amount Duration of Support</p><p>Name of Principal Investigator</p><p>Your role in the project / Percent Effort (%)</p><p>Research Title</p><p>9 REPUTATION </p><p>PROFESSIONAL MEMBERSHIP (MEDICAL AND SCIENTIFIC SOCIETIES) </p><p>State your role e.g. Member , Member of Board, Leadership Position e.g. Chairman</p><p>Name of Organization and Location (City and Country) Role / Involvement</p><p>HONORS AND AWARDS </p><p>Examples: Student Award, Scholarship, Resident/ Fellowship Award, Teacher Award, Research Awards</p><p>Name of Award Awarded By Date Awarded</p><p>EXTRAMURAL PROFESSIONAL RESPONSIBILITIES </p><p>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</p><p>Name of Institution/ Event Description Date/s</p><p>10 A. BIBLIOGRAPHY</p><p>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).</p><p>ARTICLES IN PROFESSIONAL PEER-REVIEWED JOURNALS (ORIGINAL RESEARCH) </p><p> 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</p><p>Title Upload</p><p>BOOKS, BOOK CHAPTER, EDITOR e.g. List books, book chapter, review, editorials, comment, case studies, letters invited publication in non-peer reviewed journal</p><p>Title Upload</p><p>ABSTRACTS (LIST 10 BEST) e.g. List books, book chapter, review, editorials, comment, case studies, letters invited publication in non-peer reviewed journal</p><p>Title Upload</p><p>11 PRESENTATIONS OTHER THAN INVITED LECTURES e.g. List books, book chapter, review, editorials, comment, case studies, letters invited publication in non-peer reviewed journal</p><p>Title Upload</p><p>12</p>