Fillable A FACULTY PERSONNEL RECORD (University of Michigan - Ann Arbor)

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A FACULTY PERSONNEL RECORD (University of Michigan - Ann Arbor)

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EDUCATION
First Name:
Middle Name:
Social Security Number:
UMID: Department:
Address:
City:
State:
Zip Code:
Local Telephone:
Do you have a previous University of Michigan affi lia on?
Yes
No
Do you have any rela ves employed at the U of M? If yes, please list below.
Yes
No
Name:
Name: Department:
Department:
High School:
Last Name:
STATUS
Form HR30002 Available at: h p://www.hr.umich.edu/hrris/forms/pdfs/facultypersonnelrecord.pdf
Revised 8/2014
PERSONAL INFORMATION - Give legal name as it appears/will appear on your U.S. Social Security card. The name, including all
leƩ ers and spaces, must be 50 characters or less.
Local/Current Mailing Address - For University Correspondence
Date Prepared:
Year From:
If yes, please list type of affi lia on:
Affi lia on Begin Date: Affi lia on End Date:
Name while affi liated:
City, State:
Year To:
Field of Study:
Degree: Year Graduated:
Undergraduate:
Year From:
City, State:
Year To:
Field of Study:
Degree: Year Graduated:
Graduate or Professional:
Year From:
City, State:
Year To:
Field of Study:
Degree: Year Graduated:
License:
Year From:
City, State:
Year To:
Field of Study:
Degree: Year Graduated:
LANGUAGES
List foreign language in which you have some
profi ciency and check proper columns.
Reading
Speaking
Understanding
Wri ng
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
Good
Fair
The University of Michigan, as an equal opportunity/affi rma ve ac on employer, complies with all applicable federal and state laws regarding non-
discrimina on and affi rma ve ac on. The University of Michigan is commi ed to a policy of equal opportunity for all persons and does not discrimi-
nate on the basis of race, color, na onal origin, age, marital status, sex, sexual orienta on, gender iden ty, gender expression, disability, religion,
height, weight, or veteran status in employment, educa onal programs and ac vi es, and admissions. Inquiries or complaints may be addressed
to the Senior Director for Ins tu onal Equity, and Title IX/Sec on 504/ADA Coordinator, Offi ce of Ins tu onal Equity, 2072 Administra ve Services
Building, Ann Arbor, Michigan 48109-1432, 734-763-0235, TTY 734-647-1388.
Name: Department:
FACULTY PERSONNEL RECORD
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Form HR30002 Available at: h p://www.hr.umich.edu/hrris/forms/pdfs/facultypersonnelrecord.pdf
Revised 8/2014
LIST AND DESCRIBE OTHER SPECIAL COMPETENCIES:
LIST AND DESCRIBE SPECIAL INTERESTS:
OCCUPATIONAL HISTORY - List chronologically all posiƟ ons held, including military service. Include each year since graduaƟ on
from undergraduate college.
Organiza on:
City:
Year From: Year To:
Posi on/Title:
State:
HONORS - Honorary Degrees:
Degree:
Ins tu on:
Year:
HONORS - Other Academic Honors (Awards, medals, honorary fellowships, etc.):
Honor:
Awarded By:
Year:
UMID:
Name (Last, First, Middle):
PERSONAL INFORMATION:
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Form HR30002 Available at: h p://www.hr.umich.edu/hrris/forms/pdfs/facultypersonnelrecord.pdf
Revised 8/2014
MEMBERSHIPS AND SERVICE - Past and present service, professional or personal, to naƟ onal, state, or local government or
other civic acƟ viƟ es.
Agency:
Place:
Year From: Year To:
Service or Posi on:
PUBLICATIONS - Give Ɵ tles, references, dates, pages and other facts relaƟ ng to publicaƟ ons and other achievements.
Title:
References:
Facts:
PERSONAL INFORMATION:
MEMBERSHIPS (AND OFFICIAL POSITIONS) in professional, honorary, and learned socieƟ es:
Organiza ons (Memberships):
Years:
Year From: Year To:
Offi cial Posi on:
Pages: Dates:
FACULTY PERSONNEL RECORD
UMID:
Name (Last, First, Middle):
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CERTIFICATION
Regents’ Bylaw 3.10 s pulates the condi ons governing the assignment of property rights to members of the University faculty and
staff . Unless otherwise provided by ac on of the Regents:
1.) Patents and copyrights issued or acquired as the result of or in connec on with administra on, research, or other educa onal
ac vi es conducted by members of the University staff and supported directly or indirectly (e.g., through the use of Univer-
sity resources or facili es) by funds administered by the University, regardless of the source of such funds, and all royal es or
other revenues derived there from shall be the property of the University.
2.) Computer so ware created by members of the University staff in connec on with administra on, research, or other edu-
ca onal ac vi es supported directly or indirectly by funds administered by the University, regardless of the source of such
funds, shall be the property of the University. Such computer so ware may be made available for use on a nonexclusive basis
by those who pay appropriate charges to reimburse the University for the costs of development, distribu on, and reproduc-
on.
3.) The provisions of 1 and 2, supra, shall apply unless they are inconsistent with the terms of any applicable agreement with a
third-party sponsor or provider of funds in which case the University’s agreement with such sponsor or provider shall control.
4.) Patents, copyrights, and property rights in computer so ware resul ng from ac vi es which have received no support, direct
or indirect, from the University shall be the property of the inventor, author, or creator thereof, free of any limita on which
might otherwise arise by virtue of University employment.
5.) In cases which involve both University-supported ac vity and independent ac vity by a University staff member, patents,
copyrights, or other property rights in resul ng work products shall be owned as agreed upon in wri ng and in advance of an
exploita on thereof by the aff ected staff member and the Vice-President for Research in consulta on with the Commi ee on
Patents and Copyrights and with the approval of the University’s Offi ce of General Counsel. It is understood that such agree-
ments shall con nue to recognize the tradi onal faculty and staff preroga ves and property rights concerning intellectual
work products.
Consistent with the cons tu onal requirement, State of Michigan Act 22, 1951, University staff members as a condi on of appoint-
ment, shall swear to or affi rm the following oath:
I do solemnly swear (or affi rm) that I will support the Cons tu on of the United States of America and the Cons tu on of the State of
Michigan, and that I will faithfully discharge the du es of my posi on and subsequent posi ons, according to the best of my ability.
Form HR30002 Available at: h p://www.hr.umich.edu/hrris/forms/pdfs/facultypersonnelrecord.pdf
Revised 8/2014
Date:
Signature of Applicant:
InformaƟ on on this form may be used in preparaƟ on of news arƟ cles. If
you do not want this informaƟ on used in this way, please check this box:
I cer fy that the answers on this document are true to the best of my knowledge. I realize that all the informa on furnished by me is
important and that the University will rely on such informa on in engaging me and in con nuing my employment. I also realize that this
informa on may be verifi ed by the University and that any misrepresenta on of facts may cons tute cause for dismissal. In this connec-
on I authorize all previous employers to cooperate with the University and to release on a confi den al basis any informa on they may
have concerning me. I agree to abide by all University rules and regula ons.
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A FACULTY PERSONNEL RECORD (University of Michigan - Ann Arbor)

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Completed 12 February 2022

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