NEW APPOINTMENT SHEET: Tenure-eligible Investigators 1. CANDIDATE INFORMATION Last Name First Name NPI Number (clinicians only) Current position at NU? No Yes (specify): Prior position at NU? No Yes (specify): 2. PROPOSED APPOINTMENT Appointment Start Date Primary Department (and Division, if applicable) City, State, Zip Code Office Mailing Address Street Address & Suite – Secondary Department(s) (and Division(s), if applicable) FAO# (from business plan database) (select 1) Career Pathway Rank Tenure Tenure Clock Basis* Assistant Prof Investigator Scientist Tenure-eligible _____ years FT Associate Prof Physician-Scientist Academic FT *Note: Appointments with an academic basis are fully funded by an approved affiliate & receive no paycheck from NU. Paid Salary Sources NMH NLFH NM Central Dupage NM Delnor NM Regional Medical Group NU NMG Children’s PFF RIC Jesse Brown VA Stroger Other: Hospital Privileges (Check all that apply; please prioritize by ranking as 1, 2, etc. if more than one hospital is checked) ____ NM CDH ____ Lurie Children’s ____ RIC ____ Other (specify): ____ NMH ____ NM Delnor ____ Jesse Brown VA ____ Stroger ____ No privileges ____ NLFH 3. RESEARCH QUESTIONNAIRE Obtain research questionnaire from candidate and email completed questionnaire to FAO 4. SUBMISSION TO FAO Send paper copies of the following documents to FAO in the order listed: Guidance: myHR Codes This form, completed Position Type: FAC Posn Category: REG Prior correspondence with FAO regarding special circumstances, if applicable Rank Job Code AR* Personal Data Form, completed and signed by candidate Instructor 100079 Y Position Data/Appointment Forms, prepared and signed by department If current/former NU position, print forms from myHR (has employee ID) and Assistant Professor 100021 N update instead of completing blank forms Associate Professor 100018 N If secondary appt(s), include one set prepared and signed by each dept. If paid by NMG through an NU paycheck, include the Member” set of forms “NMG Professor 100022 N approved by NMG NMG Member 100019 N If basis, fill in appt. indicator field on appointment form: “academic” Academic FT=ACAD *AR=Annual Renewable
NEW APPOINTMENT SHEET: Tenure-eligible Investigators 1. CANDIDATE INFORMATION Last Name First Name NPI Number (clinicians only) Current position at NU? Prior position at NU? No Yes (specify): No Yes (specify): 2. PROPOSED APPOINTMENT Primary Department (and Division, if applicable) Appointment Start Date Office Mailing Address – Street Address & Suite City, State, Zip Code Secondary Department(s) (and Division(s), if applicable) FAO# (from business plan database) Career Pathway (select 1) Rank Tenure Tenure Clock Basis* Investigator Scientist Physician-Scientist Assistant Prof Associate Prof Tenure-eligible _____ years FT Academic FT *Note: Appointments with an academic basis are fully funded by an approved affiliate & receive no paycheck from NU. Paid Salary Sources NU NMG NMH NLFH NM Central Dupage NM Delnor NM Regional Medical Group Children’s PFF RIC Jesse Brown VA Stroger Other: Hospital Privileges (Check all that apply; please prioritize by ranking as 1, 2, etc. if more than one hospital is checked) ____ NMH ____ NLFH ____ NM CDH ____ NM Delnor ____ Lurie Children’s ____ Jesse Brown VA ____ RIC ____ Stroger ____ Other (specify): ____ No privileges 3. RESEARCH QUESTIONNAIRE Obtain research questionnaire from candidate and email completed questionnaire to FAO 4. SUBMISSION TO FAO Send paper copies of the following documents to FAO in the order listed: This form, completed Prior correspondence with FAO regarding special circumstances, if applicable Personal Data Form, completed and signed by candidate Position Data/Appointment Forms, prepared and signed by department If current/former NU position, print forms from myHR (has employee ID) and update instead of completing blank forms If secondary appt(s), include one set prepared and signed by each dept. If paid by NMG through an NU paycheck, include the “NMG Member” set of forms approved by NMG If “academic” basis, fill in appt. indicator field on appointment form: Academic FT=ACAD Guidance: myHR Codes Position Type: FAC Posn Category: REG Rank Job Code AR* Instructor 100079 Y Assistant Professor 100021 N Associate Professor 100018 N Professor 100022 N NMG Member 100019 N *AR=Annual Renewable