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Clinical Faculty Application

First Name (required)

Last Name (required)

Your Email (required)

Ethnic Background

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)?

YESNO

Please select one or more racial categories to describe yourself:
(Use CTRL + click for PC or Command + click for Mac to select multiple categories)

Note:
(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).

Documents:

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:

        Julieta Rajlevsky
        UH Department of Medicine
        1356 Lusitana St., 7th Floor
        Honolulu, HI 96813
        Fax: 808-586-7486
        Email: jlrajlev@hawaii.edu

- 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)

I agree to spend 60 hours in each calendar year in formal teaching activities. (Please select YES or NO)
YESNO

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):

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)
YESNO

Guidelines for Appointment to Clinical Faculty

Questions? (You can call Julieta Rajlevsky at 808-586-7478 or email her at jlrajlev@hawaii.edu)

Also, you can leave any comments you have here:

Type your full name below, which will be your Signature on this form:

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