3. 4. Will the adjunct faculty member ever work in patient care areas? Type in applicable boxes. X’s No Yes Will provide patient care or clinical services as part of faculty practice responsibilities – Yes Will supervise students in patient care areas – Yes Will write prescriptions – What are the for the appointment and work assignment? individual’s qualifications Highest Degree and Discipline Professional Credentials Professional Licensure Other Qualifications What will be the financial compensation for the work assignment? Type X in one box. If provide the “Paid,” compensation per semester. Unpaid / volunteer Paid Compensation per Semester $ From which fund(s) will this adjunct faculty member be paid? Type the account number(s) and the percentage allocated from each account, if applicable. Percentages must total 100%. Fund 1 % % Fund 2 % % Other Information or Comments Name of Requester Contact Person (if different from the Requester) Save a copy of this request for your file. Then, email an electronic copy of the request along with a copy of the faculty current CV or resume to and . member’s Approval/Additional Comments (for Office of the Dean’s use)
3. 4. Will the adjunct faculty member ever work in patient care areas? Type X’s in applicable boxes. No Yes – Will provide patient care or clinical services as part of faculty practice responsibilities Yes – Will supervise students in patient care areas Yes – Will write prescriptions What are the individual’s qualifications for the appointment and work assignment? Highest Degree and Discipline Professional Credentials Professional Licensure Other Qualifications What will be the financial compensation for the work assignment? Type X in one box. If “Paid,” provide the compensation per semester. Unpaid / volunteer Paid Compensation per Semester $ From which fund(s) will this adjunct faculty member be paid? Type the account number(s) and the percentage allocated from each account, if applicable. Percentages must total 100%. Fund 1 % % Fund 2 % % Other Information or Comments Name of Requester Contact Person (if different from the Requester) Save a copy of this request for your file. Then, email an electronic copy of the request along with a copy of the faculty member’s current CV or resume to and . Approval/Additional Comments (for Office of the Dean’s use)
Faculty-Appointment-Request-Form-Adjunct-Faculty.docx