UNIVERSITY OF ILLINOIS AT CHICAGO



SALARIED (1 – 50%) CLINICAL AND ADJUNCT NON-TENURE TRACKPROMOTION FORMS – ACADEMIC YEAR 2018-19*CANDIDATE’S PERSONNEL & APPOINTMENT INFORMATION MUST BE ENTERED AS LISTED IN BANNER/HR FRONT END*Candidate: Last Name, First Name & Middle (if applicable) UIN #: UIN #College: Select College for Primary AppointmentDepartment: Unit Name%FTE: %FTE %Joint Appointment College: Select Joint College (if applicable)Select Joint Unit Type: Joint Unit Name%FTE: %FTE%Courtesy Appt. (0%FTE/UNPAID): Select Courtesy Appt. CollegeSelect Unit Type: Unit Name(s)Present Personnel Appointment:Rank: Select Track Select RankJoint Rank: Joint RankTenure Code: Select CodeJoint Tenure Code: Select Joint CodeTenure Code Legend:N = Non-Tenure TrackM = Multi-Year ContractAppointed or Promoted to Present Rank: Select Month – YearCourtesy Rank (if applicable): Select Courtesy RankProposed Personnel Action:Rank: Select Track Select Rank Joint Rank: Joint RankTenure Code: Select CodeJoint Tenure Code: Select Joint CodeFaculty Candidate Attestation: FORMCHECKBOX To the best of my knowledge, the information to which I have access that is provided in this dossier (i.e., non-confidential components) is true and accurate. FORMCHECKBOX I do not have a conflict of interest or a dual relationship with the Paper Preparer, as defined by Section 2.F.3 (Voting and Dual Relationships) and Section 3.D (Responsibility for the Case) of the Clinical Non-Tenure System Promotion and Tenure Guidelines, Part I: Campus Policies and Procedures. Faculty Candidate: Last, First Name & Middle (if applicable)Name (Print)SignatureDate Paper Preparer Attestation: FORMCHECKBOX To the best of my knowledge, the information to which I have access that is provided in this dossier (i.e., non-confidential components) is true and accurate. FORMCHECKBOX I do not have a conflict of interest or a dual relationship with the Candidate, as defined by Section 2.F.3 (Voting and Dual Relationships) and Section 3.D (Responsibility for the Case) of the Clinical Non-Tenure System Promotion and Tenure Guidelines, Part I: Campus Policies and Procedures. Paper Preparer: Last, First NameName (Print)SignatureDate Paper Preparer is also the Unit Executive Officer/Equivalent: FORMCHECKBOX YES FORMCHECKBOX NOENDORSEMENTS: UNIT, COLLEGE, AND CAMPUSCandidate: Last Name, First Name & Middle (if applicable) ENDORSEMENTNON-ENDORSEMENT(COMPLETE FOR APPLICABLE REVIEW LEVELS) FORMTEXT ????? FORMTEXT ????? FORMTEXT Type NameUnit Executive Officer (U.E.O.)/Equivalent Name/SignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT Type NameJoint U.E.O./Equivalent Name /Signature (if applicable)Date FORMTEXT ????? FORMTEXT ????? FORMTEXT Type NameRegional Dean Name and Signature (if applicable)Date FORMTEXT ????? FORMTEXT ?????Charles E. Ray, Jr., MD, PhDCollege Dean or Unit Director Name and SignatureDate FORMTEXT ????? FORMTEXT ?????Joint Dean Name and Signature (if applicable)DateENDORSEMENTNON-ENDORSEMENT______________________________________________________________________________________Provost and Vice Chancellor for Academic AffairsDateENDORSEMENTNON-ENDORSEMENT______________________________________________________________________________________Vice Chancellor for Health AffairsDateTable of Contentscover Page1ENDORSEMENT PAGE………………………………………………………...................................................2 TOC \o "1-3" \h \z \u Table of Contents PAGEREF _Toc509930232 \h 3ACADEMIC AND EMPLOYMENT INFORMATION PAGEREF _Toc509930233 \h 51.Nature of Present Appointment PAGEREF _Toc509930234 \h 52.Education PAGEREF _Toc509930235 \h 53.Post-Doctoral Information PAGEREF _Toc509930236 \h 54.Licensing and/or Certifications PAGEREF _Toc509930237 \h 55. Academic & Professional Positions Since Terminal Degree and Post-Doctoral Training PAGEREF _Toc509930238 \h 6SUMMARY OF COMMITTEE REVIEWS PAGEREF _Toc509930239 \h 7Voting Justifications PAGEREF _Toc509930240 \h 8STATEMENT OF COLLEGE NORMS, EXPECTATIONS, AND STANDARDS OF EXCELLENCE PAGEREF _Toc509930241 \h 9STATEMENT OF UNIT NORMS, EXPECTATIONS, AND STANDARDS OF EXCELLENCE PAGEREF _Toc509930242 \h 9DESCRIPTION OF COLLEGE PROCESS USED FOR PEER EVALUATION OF CLINICAL NON-TENURE TRACK FACULTY PAGEREF _Toc509930243 \h 10I. TEACHING ABILITY AND PERFORMANCE PAGEREF _Toc509930244 \h 11A. ACTIVITIES PAGEREF _Toc509930245 \h 111.Lectures and Seminars PAGEREF _Toc509930246 \h 112.Small Group Teaching PAGEREF _Toc509930247 \h 133.Clinical Teaching PAGEREF _Toc509930248 \h 154.Other Teaching Activities and Curricular Development PAGEREF _Toc509930249 \h 175.Curricular Development PAGEREF _Toc509930250 \h 17B. EVALUATION OF TEACHING AND RELATED ACTIVITIES AT UIC PAGEREF _Toc509930251 \h 181.Summary of Student Evaluations of Faculty Teaching.* PAGEREF _Toc509930252 \h 182.Formal Recognition of Distinction in Teaching PAGEREF _Toc509930253 \h 183.Candidate's Statement on Teaching Goals, Approaches and Accomplishments PAGEREF _Toc509930254 \h 19II. PATIENT CARE ACTIVITIES PAGEREF _Toc509930255 \h 20A. SPECIALTY/SUBSPECIALTY PAGEREF _Toc509930256 \h 20B. BOARD CERTIFICATION [NAME OF BOARD(S) AND DATE(S)] PAGEREF _Toc509930257 \h 20C. HOSPITAL PRIVILEGES (CURRENT) PAGEREF _Toc509930258 \h 20III. SCHOLARLY ACTIVITIES PAGEREF _Toc509930259 \h 21A. AREA(S) OF SCHOLARLY INTEREST PAGEREF _Toc509930260 \h 21B. PEER RECOGNITION FOR SCHOLARLY ACTIVITIES PAGEREF _Toc509930261 \h 21C. PUBLICATIONS OR OTHER CREATIVE WORK RELEVANT TO THE DISCIPLINE PAGEREF _Toc509930262 \h 21D. SPONSORED RESEARCH ACTIVITIES (if applicable) PAGEREF _Toc509930263 \h 23IV. SERVICE PAGEREF _Toc509930264 \h 24A. SERVICE TO THE COLLEGE OF MEDICINE OR UIC PAGEREF _Toc509930265 \h 24B. SERVICE TO THE PROFESSION/DISCIPLINE PAGEREF _Toc509930266 \h 24V. EVALUATIONS PAGEREF _Toc509930267 \h 25A. LETTERS FROM FORMER STUDENTS/RESIDENTS/FELLOWS PAGEREF _Toc509930268 \h 25B. EXTERNAL LETTERS OF REFERENCE PAGEREF _Toc509930269 \h 261. List of Referees Contacted PAGEREF _Toc509930270 \h 262. Copy of Letter(s) of Request for Referee’s Comments PAGEREF _Toc509930271 \h 263. List of all Materials Sent to Each Reviewer PAGEREF _Toc509930272 \h 264. Referee’s Information PAGEREF _Toc509930273 \h 27C. LETTERS OF SUPPORT SOLICITED BY THE U.E.O./PAPER PREPARER (with input from the candidate) PAGEREF _Toc509930274 \h 32D. LETTER(S) FOR COURTESY APPOINTMENT(S) (IF APPLICABLE) PAGEREF _Toc509930275 \h 33E. EVALUATION FROM DEPARTMENTAL COMMITTEE PAGEREF _Toc509930276 \h 34F. EVALUATION FROM COLLEGE P&T COMMITTEE PAGEREF _Toc509930277 \h 35G. EVALUATION FROM COLLEGE’S PROCESS FOR REVIEW OF CLINICAL NON-TENURE TRACK FACULTY PAGEREF _Toc509930278 \h 36H. EVALUATION FROM UNIT EXECUTIVE OFFICER / EQUIVALENT PAGEREF _Toc509930279 \h 37I. EVALUATION FROM DEAN PAGEREF _Toc509930280 \h 381.Evaluation from Regional Dean (if applicable) PAGEREF _Toc509930281 \h 382.Evaluation from College Dean PAGEREF _Toc509930282 \h 39ACADEMIC AND EMPLOYMENT INFORMATION1.Nature of Present Appointmenta.Percentage of time (total UIC employment): 100% FORMCHECKBOX Other FORMCHECKBOX FORMTEXT ????? %2.Educationa.Highest degree: FORMTEXT ?????b.Year awarded: FORMTEXT ?????c.Institution: FORMTEXT ?????d.Department: FORMTEXT ?????e.Dissertation/thesis title: FORMTEXT ?????f.Thesis Advisor Name: FORMTEXT ?????3.Post-Doctoral Information(Clinicians should include residency/fellow training.)a.List Post-Doctoral appointments: FORMTEXT ?????b.Name of Post-doctoral Advisor: FORMTEXT ?????4.Licensing and/or CertificationsProvide a list of all professional licensing and/or certifications with dates.(If pending, give expected date of completion.)1) FORMTEXT ?????2) FORMTEXT ?????3) FORMTEXT ?????4) FORMTEXT ?????5) FORMTEXT ?????5. Academic & Professional Positions Since Terminal Degree and Post-Doctoral TrainingList in chronological order academic, professional, and other relevant positions held SINCE the terminal degree and Post-doctoral training, with inclusive dates, rank or title, and name of institution. Include information for appointment at UIC and account for gaps in academic career, if pertinent. If necessary, attach extra page(s). It is not necessary to add page numbers in this section.#DatesRank/TitleInstitution/Organization1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SUMMARY OF COMMITTEE REVIEWSCandidate: Last Name, First Name & Middle (if applicable) College: Select College for Primary AppointmentRegional Site: Select Regional SiteJoint Appt. College: Select Joint CollegeUnit(s): FORMTEXT For Joint Appts. List All Units with (%FTE) Next to each UnitUnit P&T Committee Review:* Give a figure (“0”, if appropriate) in each of the six categories*Total # of Members YES NO ABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date:Joint Unit P&T Committee Review (if applicable):* Give a figure (“0”, if appropriate) in each of the six categories*Total # of Members YES NO ABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date:Joint College or Regional Site P&T Committee Review (if applicable):* Give a figure (“0”, if appropriate) in each of the six categories*Total # of Members YES NO ABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date:College P&T Committee Review:* Give a figure (“0”, if appropriate) in each of the six categories*Total # of Members YES NO ABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date:College Executive Committee P&T Review (if applicable):* Give a figure (“0”, if appropriate) in each of the six categories*Total # of Members YES NO ABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: Charles E. Ray, Jr., MD, PhDSignature:Date:Campus P&T Committee Review:* Give a figure (“0”, if appropriate) in each of the six categories*Total # of Members YES NO ABSTAINABSENTNOT ELIGIBLE** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name of Chair: FORMTEXT ?????Signature:Date:Voting Justifications**Include brief explanation(s) as to why members were “Not Eligible” (NE) to vote for each level and/or include Voting Justifications if needed, as inserted page(s) in the PDF. It is not necessary to add page numbers in this section.College level: Committee members are considered Not Eligible (NE) 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 NORMS, EXPECTATIONS, AND STANDARDS OF EXCELLENCENOTE: please insert the appropriate information from the College of Medicine Norms Statement[] FORMTEXT ?????STATEMENT OF UNIT NORMS, EXPECTATIONS, AND STANDARDS OF EXCELLENCE**Include Statements for all Ranks within the Clinical or Adjunct Non-Tenure Track(Include as separate page(s). It is not necessary to add page numbers in this section.)If the unit does not have department-specific norms, indicate that the department follows the College of Medicine Norms.DESCRIPTION OF COLLEGE PROCESS USED FOR PEER EVALUATION OF CLINICAL NON-TENURE TRACK FACULTYThe College of Medicine does not have a separate process for review of clinical non-tenure faculty.**If the department has a separate process, include it below or as a separate page(s).It is not necessary to add page numbers in this section.I. TEACHING ABILITY AND PERFORMANCEA. ACTIVITIESLectures and SeminarsIdentify the candidate’s specific lecture and/or seminar teaching activities in relation to UIC medical students and trainees over the past five years. This sheet can be reproduced as many times as necessary to reflect all of the candidate’s activities. FORMCHECKBOX Check here if noneLectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Lectures/SeminarsLecture/Seminar Title: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingIdentify the candidate’s specific small group teaching activities in relation to UIC medical students and trainees over the past five years. This sheet can be reproduced as many times as necessary to reflect all of the candidate’s activities. FORMCHECKBOX Check here if noneSmall Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Small Group TeachingSubject Topic: FORMTEXT ?????Course Title: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical TeachingIdentify the candidate’s specific clinical teaching activities in relation to UIC medical students and trainees over the past five years. This sheet can be reproduced as many times as necessary to reflect all of the candidate’s activities. FORMCHECKBOX Check here if noneClinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Clinical Teaching/AttendingSpecific Teaching Activity: FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Number of Students/Trainees per Session: FORMTEXT ?????Length of Rotation: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Other Teaching Activities and Curricular DevelopmentIdentify other types of teaching activities external to UIC done by the candidate over the past five years. This sheet can be reproduced as many times as necessary to reflect all of the candidate’s activities. FORMCHECKBOX Check here if noneOther Teaching Activities: (Specify): FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Other Teaching Activities: (Specify): FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Other Teaching Activities: (Specify): FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Other Teaching Activities: (Specify): FORMTEXT ?????Level of Students/Trainees: FORMTEXT ?????Average Number of Students/Trainees per Session: FORMTEXT ?????Date(s) Given: FORMTEXT ?????Curricular DevelopmentDescribe the candidate’s role in any curricular development or teaching innovation over the past five years. Include the creation and implementation of new courses. FORMCHECKBOX Check here if none FORMTEXT ?????B. EVALUATION OF TEACHING AND RELATED ACTIVITIES AT UICSummary of Student Evaluations of Faculty Teaching.*Summarize the results of student evaluations of the candidate's overall teaching effectiveness. If narrative comments from student evaluations are included, all comments from all students in that course should be provided. If an assessment scale is used, identify the scale (i.e. candidate evaluation on a scale of 1 to 5 where 5=excellent).DEPARTMENTS MAY USE AN ALTERNATE FORM FOR SUMMARIZING STUDENT EVALUATIONS; HOWEVER, STUDENT EVALUATIONS MUST BE PRESENTED AS SUMMARIZED DATA. #Semester/TermCourse Number(if applicable)Course Title / Type of Student (medical student, resident, fellow, etc.)*Average Rating+ SD(n/N)1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????*Average of students' ratings of the "Overall Teaching Effectiveness" (or equivalent) of the candidate, on a scale of 5 (Excellent) to 1 (Poor). SD = standard deviation; n = number of students who rated the candidate in that course; N = total number of students in that course.(Additional pages may be added as needed.)Formal Recognition of Distinction in TeachingPlease indicate nature of and criteria for recognition as well as the dates of awards. FORMCHECKBOX Check here if none FORMTEXT ?????Candidate's Statement on Teaching Goals, Approaches and AccomplishmentsThe candidate should explain his/her philosophy of education, describe the place of teaching in his/her career goals, assess his/her progress toward those goals, and describe his/her plan for future teaching activities.(Fit on one page; no smaller than 10 pt font. It can be included as a separate page. It is not necessary to add page numbers in this section.) FORMTEXT ?????II. PATIENT CARE ACTIVITIESA. SPECIALTY/SUBSPECIALTY FORMCHECKBOX Check here if none FORMTEXT ?????B. BOARD CERTIFICATION [NAME OF BOARD(S) AND DATE(S)] FORMCHECKBOX Check here if none FORMTEXT ?????C. HOSPITAL PRIVILEGES (CURRENT) FORMCHECKBOX Check here if none FORMTEXT ?????Provide a description of the participation of trainees in the candidate’s clinical practice. (Include details on type of practice, patient population, referral base, and special emphases or other distinguishing features.) FORMTEXT ?????III. SCHOLARLY ACTIVITIESA. AREA(S) OF SCHOLARLY INTEREST FORMCHECKBOX Check here if none FORMTEXT ?????B. PEER RECOGNITION FOR SCHOLARLY ACTIVITIES(e.g. funding awards, invitations to speak or present, service on advisory committees, etc.) FORMCHECKBOX Check here if none FORMTEXT ?????C. PUBLICATIONS OR OTHER CREATIVE WORK RELEVANT TO THE DISCIPLINEList in chronological order. Underline senior author in all categories, and asterisk (*) refereed publications if listed in categories other than c. The senior author is defined as the major contributor to the publication. If there is a certain significance in the order of authors in multi-author publications in the discipline, please provide a brief summary of the practice.a.Books and monographs FORMCHECKBOX Check here if none FORMTEXT ?????b.Edited volumes and translations FORMCHECKBOX Check here if none FORMTEXT ?????c.Articles in refereed journals(Do not abbreviate titles; give inclusive page numbers.If there is certain significance in the order of authors in multi-author publications in the discipline, please provide a brief summary of the practice). FORMCHECKBOX Check here if none FORMTEXT ?????d.Refereed abstracts and conference proceeding articles(Do not abbreviate titles; give inclusive page numbers. If there is certain significance in the order of authors in multi-author publications in the discipline, please provide a brief summary of the practice). FORMTEXT ?????e.Other articles, including bulletins and technical reports(Give inclusive page numbers.) FORMTEXT ?????f.Chapters in books(Give inclusive page numbers.) FORMTEXT ?????g.Book reviews(Give inclusive page numbers.) FORMTEXT ?????h.Creative works(e.g., poetry, composition, exhibitions) FORMTEXT ?????i.Patents FORMTEXT ?????j.Other (e.g., notes and comments) FORMTEXT ?????D. SPONSORED RESEARCH ACTIVITIES (if applicable)In chronological order, list sponsored research activities for a period not longer than the most recent five years (post-doctoral data may not be included). List all grant applications, even if unfunded.#Date ofSubmissionRole of Candidate*AgencyTitle of ProposalAmount**RequestedAmount**FundedFunding Period1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????16 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????17 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????18 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????19 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????*List PI name, if other than candidate.**In multi-investigator projects, list both total amount and amount attributable to candidate, e.g., $375,750/$123,000. Indicate whether amount is total cost (TC), i.e. direct + indirect, or total direct cost (TDC). Funding and submissions are subject to verification by the Office of the Vice Chancellor for Research.IV. SERVICEA. SERVICE TO THE COLLEGE OF MEDICINE OR UICIdentify specific service to the College of Medicine or UIC over the past five years. Also include memberships on departmental, site, College and University committees. FORMCHECKBOX Check here if none FORMTEXT ?????B. SERVICE TO THE PROFESSION/DISCIPLINEIdentify specific service to the profession/discipline over the past five years. Include memberships on advisory committees for or consultantships to hospitals and educational, clinical, or other similar institutions. FORMCHECKBOX Check here if noneV. EVALUATIONSA. LETTERS FROM FORMER STUDENTS/RESIDENTS/FELLOWSLetters from former students/residents/fellows or others supervised by the candidate may be appropriate to assist in appraising the candidate’s clinical teaching. All replies to this request must be included. FORMCHECKBOX Check here if noneInsert former trainees/students and peer evaluation letters following this page. It is not necessary to add page numbers in this section.List names of individuals contacted below. FORMTEXT ?????B. EXTERNAL LETTERS OF REFERENCELetters of reference should be solicited from not fewer than three but no more than five referees.Referees should have no past or present direct professional association with the candidate, should be at or above the academic rank for which the candidate is being proposed, and may be non-tenured.All communications pertaining to the initial requests for an evaluation of the candidate and replies that were sent and received by the Unit must be included in the candidate’s file, even if the reviewer’s letter is a simple statement of inability or unwillingness to serve.1. List of Referees Contacteda. Those Who Accepted: FORMTEXT ?????b. Those Who Declined: FORMTEXT ?????c. Those Who Did Not Respond: FORMTEXT ?????2. Copy of Letter(s) of Request for Referee’s CommentsInsert one copy of letter requesting referee's comments, including one copy (if applicable) of all communications inquiring whether the referee is willing to serve. (See sample letter of request included in Part III, “Instructions” Section 7,V.B). FORMTEXT ?????3. List of all Materials Sent to Each Reviewer(May be omitted here, if this information is contained in the sample letter under number 2 above) In the case of unpublished materials, it should be clearly specified in what form and how much material was sent (outline, draft, proofs, etc.). FORMTEXT ?????4. Referee’s InformationProvide the information below for each Referee. Each Letter from a Referee should follow the Referee’s Information Page. Delete any unneeded Information 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). It is not necessary to add page numbers in this section.b. Referee 2Name 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). It is not necessary to add page numbers in this section.c. Referee 3Name 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). It is not necessary to add page numbers in this section.d. Referee 4Name 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). It is not necessary to add page numbers in this section.e. Referee 5Name 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). It is not necessary to add page numbers in this section.C. LETTERS OF SUPPORT SOLICITED BY THE U.E.O./PAPER PREPARER (with input from the candidate)(Optional)Letters of support for the candidate are optional and may be included from past or present scholarly/research/clinical colleagues, former graduate and post-doctoral advisors/mentors, and any relevant others. **Insert letters of support on following page(s). It is not necessary to add page numbers in this section.List names of individuals contacted below. FORMTEXT ?????D. LETTER(S) FOR COURTESY APPOINTMENT(S) (IF APPLICABLE)(If Applicable)Paper preparer(s) must solicit letters from the Unit Executive Officer(s) of the Unit(s) in which the candidate holds a Courtesy Appointment. Letters should document the contributions of the candidate in the courtesy unit.**Insert letters on the following page(s). It is not necessary to add page numbers in this section.E. EVALUATION FROM DEPARTMENTAL COMMITTEE(IF APPLICABLE – if there is a disagreement between the Unit P&T Committee and the Unit Executive Officer)**Insert evaluation from departmental committee on the following page(s). It is not necessary to add page numbers in this section.F. EVALUATION FROM COLLEGE P&T COMMITTEE(IF APPLICABLE – if there is a disagreement between the College P&T Committee and the Dean)**Insert evaluation from college committee on the following page(s). It is not necessary to add page numbers in this section.G. EVALUATION FROM COLLEGE’S PROCESS FOR REVIEW OF CLINICAL NON-TENURE TRACK FACULTY(IF APPLICABLE – if the college has a process, include it, If not, indicate that the college does not have a separate process.)**Insert evaluation on the following page(s). It is not necessary to add page numbers in this section.The College of Medicine does not have a separate process for review of clinical non-tenure faculty.H. EVALUATION FROM UNIT EXECUTIVE OFFICER / EQUIVALENTCandidate: FORMTEXT ?????Date: FORMTEXT ?????College: MedicineDepartment: FORMTEXT ?????Unit Executive Officer/Equivalent is also the Paper Preparer: FORMCHECKBOX YES FORMCHECKBOX NO 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 below.JUSTIFICATION FOR RECOMMENDATION(Evaluation must address split votes at the department level and should be organized under the following five subheadings.)1. Appraisal of Candidate’s Teaching Record(Comment on the candidate's overall teaching ability, including the extent to which the candidate has matured in teaching effectiveness over the time period considered. Justify the assessment.) FORMTEXT ?????2. Appraisal of Candidate’s Contribution to Curriculum and Other Instructional Materials or Products(Describe and assess the candidate's contributions to curriculum.) FORMTEXT ?????3. Appraisal of Candidate’s Research and Scholarship, Including Contributions (if any) to Collaborative Research(Provide an assessment of the quality of the publication outlets, giving objective rankings of presses and journals where available.) FORMTEXT ?????4. Appraisal of Candidate’s Service Record (Justify this assessment and attach any supporting documents.) FORMTEXT ?????5. Overall Assessment and Justification for Recommendation FORMTEXT ????? FORMTEXT U.E.O NameUnit Executive Officer /EquivalentU.E.O./Equivalent (signature)(Place name and signature on the last page only)I. EVALUATION FROM DEANEvaluation 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 below.JUSTIFICATION FOR RECOMMENDATION(Evaluation must address split votes at the college/college executive level) FORMTEXT NameRegional DeanRegional Dean (signature)(Place name and signature on the last page only)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 below.JUSTIFICATION FOR RECOMMENDATION(Evaluation must address split votes at the college/college executive level)Charles E. Ray, Jr., MD, PhDDeanDean (signature)(Place name and signature on the last page only) ................
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