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)
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)

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:

Please Upload Curriculum Vitae and bibliography (updated within 1 year):

Please email the following required documents to:

        Erika Klimecki
        Email: imcoord@hawaii.edu

- Current copy of medical license
- Completed I9 Form (https://www.uscis.gov/i-9) + supporting documents
- Current TB Clearance within the last 12 months
- 2 letters of recommendation from a professional reference (addressed to the Chair)

My previous appointment was: (Please choose a value)
—Please choose an option—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)
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):
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

If applicable: 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 or comments? (You can also call Erika Klimecki at 808-586-7460 or email her at imcoord@hawaii.edu)

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

.

.