UNIVERSITY OF ILLINOIS AT CHICAGO



UIC COLLEGE OF MEDICINEEXPEDITED Q CONTRACTACADEMIC YEAR: ______*CANDIDATE’S PERSONNEL/APPOINTMENT INFO. MUST BE ENTERED AS LISTED IN BANNER/HR FRONT END*Candidate: Last Name, First Name & Middle (if applicable)UIN # if available: UIN #College: MedicineRegional Site: Select Regional SiteDepartment: Unit Name%FTE: %FTE%Joint or Courtesy Appt: Unit Name%FTE: %FTE%Last Appointment Held (at previous institution):Name of Institution: Rank: Select RankTenure Status: Select CodeMonth/Year Appointed/Promoted to Present Rank:Proposed Personnel Action:Rank: Select RankTenure Code: QI have read the Promotion and Tenure Policies and Procedures:Faculty Candidate:Last, First Name & Middle (if applicable) FORMTEXT ?????Name (Print)SignatureDatePaper Preparer: Last, First Name FORMTEXT ?????Name (Print)SignatureDatePaper Preparer is also the Unit Executive Officer/Equivalent: FORMCHECKBOX YES FORMCHECKBOX NOENDORSEMENTNON-ENDORSEMENT(COMPLETE FOR APPLICABLE REVIEW LEVELS)270700513144400 FORMTEXT ????? FORMTEXT ????? FORMTEXT Type NameUnit Executive Officer (U.E.O.)/Equivalent Name/SignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT Type Name2707640444400Joint U.E.O./Equivalent Name /Signature (if applicable)Date FORMTEXT ????? FORMTEXT ????? FORMTEXT Type Name2707640444400Regional Dean Name and Signature (if applicable)Date270764014096900 FORMTEXT ????? FORMTEXT ????? FORMTEXT Type NameCollege Dean or Unit Director Name and SignatureDateTable of Contents for Materials Contained in the Expedited Q Contract Dossiercover sheet1 TOC \o "1-3" \h \z \u RMATION SUMMARY FORM PAGEREF _Toc482973446 \h 3II.SUMMARY OF COMMITTEE REVIEWS PAGEREF _Toc482973447 \h 5III.STATEMENT OF COLLEGE/UNIT NORMS, EXPECTATIONS, AND STANDARDS OF EXCELLENCE PAGEREF _Toc482973448 \h 6IV.Candidate's Personal Statement on Teaching, Research and Service PAGEREF _Toc482973449 \h 7V.EVALUATIONS PAGEREF _Toc482973450 \h 8A.Letters from Former Trainees/Students PAGEREF _Toc482973451 \h 8B.External Letters of Reference PAGEREF _Toc482973452 \h 9C.Letters of Support PAGEREF _Toc482973453 \h 15D.Evaluation from Departmental P&T Committee PAGEREF _Toc482973454 \h 16E.Evaluation from Unit Executive Officer PAGEREF _Toc482973455 \h 17F.Evaluation from Regional Dean (if applicable) PAGEREF _Toc482973456 \h 18G.Evaluation from College Dean PAGEREF _Toc482973457 \h 19VI.CV AND SAMPLE PUBLICATIONS PAGEREF _Toc482973458 \h 20INFORMATION SUMMARY FORMEXPEDITED Q CONTRACTName: Department (s):196215888900409575088890036804601625590049682401625590021755101625590093345016255900Campus: Chicago PeoriaRockford Urbana Present Title: Date Awarded:435292527304006286502730400551116512826900Proposed Title: Proposed Track: Academic (RT) 5516880137159007734301523900Academic (CT) 188595017525900% salaried for University activitiesDegrees (include school, year, name of degree, honors):Post Doctoral Training (specialty, location, dates):Board Certification [name(s) of Board(s) and date(s)]:Professional Positions Held Since Terminal Degree (chronological order with dates):Specific Teaching Responsibilities (Include student populations taught, teaching setting, frequency of teaching, etc.)Specific Educational Leadership Responsibilities (List courses developed, courses directed, etc.)Specific Service Responsibilities (Include service to dept/ college/university/community)Specific Patient Care Responsibilities (Describe how clinical time is allocated, patient load/schedule, referral base, etc.)Research Productivity Since Last Personnel ActionResearch Focus:16764002984400 # of papers in refereed journals 5029201841400 # of abstracts and presentations at professional meetings5029201904900 # of books / book chapters502920203190050292013715900 # of reviews /case reports / technical bulletins Current Research Support AgencyRole of Candidate(PI or Co-I)Grant type (R01, R21, K08, industry, etc) and proposal titleTotal direct costs attributed to candidateFunding PeriodNo. of Previous Grants:22402801250940050292012509400 as P.I.Sources22402801435090050292014350900 as Co-I.SourcesMajor Awards, Fellowships, Honors, Societies, National Committees, Editorships:SUMMARY OF COMMITTEE REVIEWSCandidate: Last Name, First Name & Middle (if applicable)College: MedicineRegional Site: Select Regional SiteUnit P&T Committee Review:* Give a figure (“0”, if appropriate) in each of the six categories*Total # of MembersYESNOABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date: FORMTEXT ?????Regional Site or Joint College P&T/Executive Committee Review (if applicable):* Give a figure (“0”, if appropriate) in each of the six categories*Total # of MembersYESNOABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date: FORMTEXT ?????College P&T Committee Review:* Give a figure (“0”, if appropriate) in each of the six categories*Total # of MembersYESNOABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date: FORMTEXT ?????College Executive Committee P&T Review (if applicable):* Give a figure (“0”, if appropriate) in each of the six categories*Total # of MembersYESNOABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date: FORMTEXT ?????Voting JustificationsCommittee members are considered ineligible to vote if they have voted at a previous level in the process or if the proposed rank of the candidate is greater than their own.STATEMENT OF COLLEGE/UNIT NORMS, EXPECTATIONS, AND STANDARDS OF EXCELLENCECOLLEGE NORMSNOTE: please insert the information for the appropriate rank/track from the College of Medicine Norms Statement. FORMTEXT ?????UNIT NORMSPlease insert the information for the appropriate rank/track from the department’s norms statement.If the unit does not have department-specific norms, indicate that the department follows the College of Medicine Norms. FORMTEXT ?????Candidate's Personal Statement on Teaching, Research and ServiceThe candidate should explain his/her activities and philosophical perspectives for teaching, research and service, assess his/her progress toward those goals, and describe his/her plan for future activities. (three-page limit recommended) FORMTEXT ?????EVALUATIONSA.Letters from Former Trainees/StudentsEvaluation of the candidate’s overall teaching effectiveness may be solicited from former students/trainees. These evaluations should be solicited by the department head/chair or designee, not the candidate (although the candidate may suggest reviewers). Evaluators should be asked to describe their exposure to the candidate’s teaching, to assess the candidate’s overall teaching effectiveness on a scale of 5 (Excellent) to 1 (Poor), and to justify that assessment.List names of students contacted below.**Insert letters on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C).B.External Letters of ReferenceProvide no fewer than three but no more than five letters of reference from individuals at or above the proposed rank who are able to objectively evaluate the candidate's research, teaching and clinical skills or other service as applicable, as well as his or her professional stature in the discipline. Letters should be requested by the department head or a senior faculty member in the department using the standard external referee solicitation letter.1.List of Referees Contacted2.List of all materials sent to each reviewer. 3.Insert sample of letter requesting referee's comments4.Referee’s Information and LetterProvide the information requested for each Referee. Each Letter from a referee should follow the Referee’s Information Page. Delete any unneeded pages.a.Referee 1Name of Referee: FORMTEXT ?????Brief Biographical Sketch of Referee: FORMTEXT ?????How was this referee selected? FORMTEXT ?????Specify referee's relationship to the Candidate:(In fields that are small where acquaintance is not unusual, a statement to this effect must be provided by the department.) FORMTEXT ?????**Insert letters from referees on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C).a.Referee 2Name of Referee: FORMTEXT ?????Brief Biographical Sketch of Referee: FORMTEXT ?????How was this referee selected? FORMTEXT ?????Specify referee's relationship to the Candidate: FORMTEXT ?????**Insert letters from referees on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C)a.Referee 3Name of Referee: FORMTEXT ?????Brief Biographical Sketch of Referee: FORMTEXT ?????How was this referee selected? FORMTEXT ?????Specify referee's relationship to the Candidate: FORMTEXT ?????**Insert letters from referees on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C)a.Referee 4Name of Referee: FORMTEXT ?????Brief Biographical Sketch of Referee: FORMTEXT ?????How was this referee selected? FORMTEXT ?????Specify referee's relationship to the Candidate: FORMTEXT ?????**Insert letters from referees on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C)a.Referee 5Name of Referee: FORMTEXT ?????Brief Biographical Sketch of Referee: FORMTEXT ?????How was this referee selected? FORMTEXT ?????Specify referee's relationship to the Candidate: FORMTEXT ?????**Insert letters from referees on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C)C.Letters of Support Unit executive officers may solicit letters from individuals who have had a substantial collaboration with the candidate and/or are able to speak with personal knowledge to the candidate's research, teaching and clinical skills or other service.List names of individuals contacted below.**Insert letters on following page(s), numbered as the same page # as this page with “A” next to it and so on. (e.g. 1A, 1B, 1C).D.Evaluation from Departmental P&T Committee(Letter from committee is optional unless there is a split or negative vote)E.Evaluation from Unit Executive OfficerCandidate: FORMTEXT ?????Date: FORMTEXT ?????College: FORMTEXT ?????Department: FORMTEXT ?????Unit Executive Officer/Equivalent is also the Paper Preparer: FORMCHECKBOX YES FORMCHECKBOX NOJUSTIFICATION FOR RECOMMENDATION(should include appraisal of candidate’s teaching record, research and scholarship, service record, and provide an overall assessment and justification for recommendation)Unit Executive OfficerUnit Executive Officer (signature)(Place name and signature on the last page only)F.Evaluation from Regional Dean (if applicable)Candidate: FORMTEXT ?????Date: FORMTEXT ?????College: MedicineDepartment: FORMTEXT ????? FORMCHECKBOX I support the proposed personnel action for the reasons detailed below. FORMCHECKBOX I do not support the proposed personnel action for the reasons detailed belowJUSTIFICATION FOR RECOMMENDATION(Evaluation must address split votes at the college/college executive level) FORMTEXT Regional Dean's NameRegional DeanRegional Dean (signature)(Place name and signature on the last page only)G.Evaluation from College DeanCandidate: FORMTEXT ?????Date: FORMTEXT ?????College: MedicineDepartment: FORMTEXT ????? FORMCHECKBOX I support the proposed personnel action for the reasons detailed below. FORMCHECKBOX I do not support the proposed personnel action for the reasons detailed belowJUSTIFICATION FOR RECOMMENDATION FORMTEXT Dean's NameCollege DeanCollege Dean (signature)(Place name and signature on the last page only)VI.CV AND SAMPLE PUBLICATIONSAttach candidate’s current CV and 3 sample publications following this page.Note:CV should include information on teaching, service and research activities, including details on sponsored research. ................
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