First Name (required)
Last Name (required)
Your Email (required)
The University of Hawai‘i complies with recordkeeping requirements under federal and State civil rights laws and regulations. In accordance with these laws, the University invites employees to voluntarily self-identify their sex and race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations.
Are you Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origini regardless of race)?
Please select one or more racial categories to describe yourself:
(Use CTRL + click for PC or Command + click for Mac to select multiple categories)
White (1)American Indian or Alaska Native (2)Black or African American (3)Native Hawaiian or Part HawaiianGuamanian or ChamorroMicronesian (not Guamanian or Chamorro)SamoanTonganOther Pacific IslanderChineseFilipinoJapaneseKoreanLaotianThaiVietnameseSouth Asian and Asian Indian (4)
(1) White - A person having origins in any original peoples of Europe, the Middle East, or North Africa (e.g., persons who identify as Portuguese, German, Lebanese, Arab, Egyptian).
(2) American Indian or Alaska Native - A person having origins in any of the original peoples of North, Central, and South America and who maintains tribal affiliation or community attachment.
(3) Black or African American - A person having origins in any of the black racial groups of Africa.
(4) South Asian and Asian Indian - A person having origins in any of the original peoples of the Indian subcontinent (e.g., Indian, Pakistan, Afghanistan, Bangladesh, Bhutan, Nepal, Sri Lanka).
Application will not go to Committee until all documents are received.
Please Upload Curriculum Vitae and bibliography (updated within 1 year):
Please fax or mail the following required documents to:
UH Department of Medicine
1356 Lusitana St., 7th Floor
Honolulu, HI 96813
- Current copy of medical license
- Completed I-9 Form with necessary supporting documents (please mail original form to the address below).
- Current TB Clearance (must be a skin test or chest x-ray report, if positive)
The Department of Medicine requires 2 letters of recommendation (addressed to the Chairman) as part of the Clinical Faculty application. Please provide the names and contact information of two professional references below:
My previous appointment was: (Please choose a value)
---Clinical InstructorAssistant Clinical ProfessorAssociate Clinical ProfessorClinical ProfessorI did not have a previous faculty appointment
I agree to spend 60 hours in each calendar year in formal teaching activities. (Please select YES or NO)
Use CTRL + click for PC or Command + click for Mac to select multiple activities
These 60 hours may be spent in the following ways (please check all that you wish to participate in):
Lectures, Workshops and ColloquiaMentoringClinical Skills ExaminerClinical Skills PreceptorPBL TutorResearch AdvisorTeaching Attending at Affiliated Hospitals (Rounding with Team)Ambulatory Medicine Preceptor during Third-year Clerkship in Internal MedicineOffering A Student ElectiveOffering A Resident ElectiveContinuity Clinic for Residents
Please write the name of the Student/Resident Elective here:
I have read the guidelines for appointment to the Clinical Faculty and wish to become a member of the Clinical Faculty. (Please select YES or NO)
Guidelines for Appointment to Clinical Faculty
Questions? (You can call Julieta Rajlevsky at 808-586-7478 or email her at firstname.lastname@example.org)
Also, you can leave any comments you have here:
Type your full name below, which will be your Signature on this form:
Please enter the following