GRADUATE SCHOOL - Eastern Kentucky University



Office of Graduate Education and Research

Eastern Kentucky University

SSB 310 CPO 68

ADJUNCT/CLINICAL/PRACTITIONER GRADUATE FACULTY NOMINATION FORM

DIRECTIONS: Adjunct/Clinical/Practitioner Graduate Faculty Status may be granted to individuals who are not EKU Tenured or Tenure Track Faculty and who wish to teach graduate courses, and/or supervise clinicals, master’s theses or doctoral dissertations. Please refer to the latest Criteria for the Selection of Faculty Members for Service as Adjunct Graduate Faculty in the Faculty Handbook. The completed form must be routed through your department chair and academic dean for endorsement and transmittal to the Graduate School Office, SSB 310, CPO 68.

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|PRIMARY INFORMATION SECTION |

|Nominee’s Name: |      |Email: |      |

|Department: |      |College: |      |

|Application Type: | New Application Renewal |

|Status: Please check the box below that most closely describes your current status. |

| | EKU Lecturer, Instructor, Part-time or Visiting Faculty |

| |EKU Staff |

| |Clinical/Practitioner Professional employed by hospital, school district, government agency or other. |

| |Tenured/Tenure Track Faculty from another University or College |

| |Home Institution:       |

|Signature: | |Date: | |

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I. Educational Background

Earned at least a master’s degree in the teaching discipline

List all academic degrees and certificate/licensure earned beginning with most recent

|Institution |Year |Degree |Field |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

Note: copies of the relevant certificate/licensure must be attached

II. Experience and Leadership

Minimum of two years practice experience in the teaching area at the advanced level (attach appropriate documentation – some departments may require additional experience to meet accreditation requirements)

Leadership role in practice or in the profession (attach appropriate documentation)

III. Evidence of successful teaching experience within the past five years

a. List of undergraduate and/or graduate courses taught during the last five years

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|Prefix / Number |Title |Semester / Year |

|      |      |      |

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|      |      |      |

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b. List of comprehensive/qualifying examinations and/or thesis/dissertation committees the nominee has been a member of, if applicable.

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|Committee type |Student Name |Date Completed |

|(examination/thesis/dissertation) | | |

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|      |      |      |

IV. Courses to be taught and/or theses/dissertations supervised by this faculty (For theses and dissertations, please list appropriate course number – e.g. CHEM 899, and thesis/dissertation title)

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|Prefix / Number |Title |Semester / Year |

|      |      |      |

|      |      |      |

|      |      |      |

V. Documents to be attached: the following documents must be attached:

Evidence of Experience and Leadership (attach copies of appropriate documents indicating two to five years of practical experience and proof of leadership activities – please include copies of relevant certificates or licensure, if applicable)

And

Summary of the faculty’s teaching evaluations OR a letter from the department chair discussing the quality of applicant’s teaching.

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|ENDORSEMENTS: |

|1. |Nominated by | |Date | |

| | |Department Chair | | |

|2. |Recommended | |Date | |

| | |College Dean | | |

|3. |Approved | |Date | |

| | |Graduate School | | |

DATE OF NEXT REVIEW: _______________________________________

COMMENTS:

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