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 Agape Network Connecticut Children's Medical Center Corporation Aurora Health Care, Inc. Coral Gables Hospital (Tenet) Homestead Hospital Aventura Hospital and Medical Center Creekside Surgery Center House of Hope, Inc. (HCA) Department of Veteran Affairs: Imagos Institute of Plastic Surgery, B.E.S.T. Center Miami VA Healthcare System Inc Banyan Health Systems Dermatology Specialists of West Florida Jackson Memorial Hospital Baptist Health South Florida, Inc. Digestive Diseases Jackson North Medical Center Baptist Hospital of Miami Digestive Medicine Associates, Jackson South Community Hospital Bay Pines VA Healthcare System LLP Jesse Trice Community Health Center, Inc. Baycare Clinic, LLP Doctors Hospital Jimenez & Siman, MD, LLC Bayside Ambulatory Center Duke University Joe DiMaggio Children's Hospital Borinquen Health Care Center East Providence Urgent Care Juan P. Suarez, MD, PA Broward Health Coral Springs Eduardo Gonzalez-Hernandez, MD PLLC Kendall Family Medical Center Broward Health Imperial Point Emerald Coast Dermatology (HCA) Broward Health Medical Center EPSP Kendall Regional Medical Center Broward Health North (HCA) Fawcett Memorial Hospital (HCA) Burrell Institute for Health Policy Key Clubhouse of South Florida, Inc. & Burrell Coll Florida Back Institute Kid Care Pediatric, PA Camillus Health Concern, Inc. Florida Hospital Tampa (FHT) Kidz Medical Services, Inc. Cano Medical Dental, Inc. Florida Medical Clinic, PA La Jolla Institute for Allergy and Children's Health System of Texas Florida Physicians Group, Inc. Immunology Children's Skin Center, PA Floridian Emergency Specialists Lamas Surgical Center Citrus Health Network, Inc. Franco & Company, LLC Late Hours Urgent Care Center Cleveland Clinic Florida Gables Pediatrics, PA Lee Memorial Health System Community Aids Resource (Care Get Med Urgent Care Leon Medical Center, Inc. Resource) Guidewell Sanitas I LLC (CliniSanitas) Lung and Critical Care Specialists Community Health of South Hartford Hospital Martin Medical Center Florida, Inc. (CHI) Health Information Project (HIP) MCCI Group Holdings, LLC Community Health of South Helen B. Bentley Family Health MD Neocare, Inc Florida, Inc. (CHI) Center, Inc. Melbourne Urgent Care, Inc. Compass Health Systems Henderson County Hospital HERBERT WERTHEIM COLLEGE OF MEDICINE Modesto A. Maidique Campus, 11200 S. W. 8th St., AHC2 693, Miami FL 33199 Tel: 305.348.0570 Fax: 305.348.0570 medicine.fiu.edu Memorial Hospital Miramar Orthopedic Research Clinic of Alaska Tenet Florida Physician Services, Inc. Memorial Hospital Pembroke (ORCA) Tenet Good Samaritan Medical Center Memorial Hospital West Paladina Health Tenet Hialeah Hospital Memorial Regional Hospital Palm Medical Centers Tenet North Shore Medical Center Memorial Regional Hospital South Palmetto General Hospital (Tenet) Tenet Palmetto General Hospital Mercy Hospital (HCA) Pediatric Associates The Coyle Institute Mercy Urgent Care Pro Hospital Group, LLC Twin Cities Hospital (HCA) Metropolitan Health Networks, Inc. Public Health Trust UCSF Fresno (MetCare) Quality Surgical Care, PA Unicardio Medical Center Miami Beach Community Health Riviera Health Resort Universal Heritage Institute, Inc. Center, Inc. Robert Klein MD PA (UHI) Miami Global OBGYN, LLC Sanchez-Cazau Medical Group, PA VITAS Healthcare Corporation Miami International Medical Center Sand Dollar Psychiatric Services Wayne County Hospital and Miami Jewish Health Systems Sarasota County Public Hospital District Clinical System Miami Rescue Mission Clinic Seduction Cosmetic Surgery Center West Florida Regional Medical Center Millennium Physician Group Skin DC West Kendall Baptist Hospital Mohamed Azzouz, MD PA Smith Community Mental Health Weston Cosmetic Surgery Center Mount Sinai Medical Center South Broward Hospital District d/b/a Naval Medical Center, Portsmouth Memorial Healthcare System William Bill Kling VA Clinic Nicklaus Children's Hospital (NCH) South Florida Evaluation & Treatment North Broward Hospital District d/b/a Center GEO Broward Health South Miami Hospital North Florida Regional Medical Center Spectrum Health System (HCA) Tampa Family Health Centers, Inc. North Okaloosa Family Medicine Tenet Coral Gables Hospital HERBERT WERTHEIM COLLEGE OF MEDICINE Modesto A. Maidique Campus, 11200 S. W. 8th St., AHC2 693, Miami FL 33199 Tel: 305.348.0570 Fax: 305.348.0570 medicine.fiu.edu .