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Department of Family Medicine, University of Washington CLINICAL (University of Washington)

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Department of Family Medicine, University of Washington
CLINICAL FACULTY APPLICATION PACKET
Application Packet for
Clinical Faculty Appointment Checklist
Please provide the items below (forms enclosed):
Letter of recommendation (from Residency or Program Director)
*Please note that four letters of recommendation are required for appointment to UW paid clinical
faculty status; if the candidate is outside the University of Washington, two of these letters must also
come from outside the University. For all other ranks, only one letter of recommendation is required.
CV (see sample for formatting)
WWAMI Personal Data Form
UW Conviction/Criminal History Information
Washington State Patrol Request for Criminal History Information
*Please make sure you sign the Criminal Conviction form, and
sections C and D are filled out in the WA State Patrol form.
Please provide your business address below:
Clinic Name
____________________________________________________________
Address
____________________________________________________________
City, State, Zip
____________________________________________________________
For questions or concerns, please contact the Clinical Faculty Coordinator at
206-543-3101 or at cfcoord@uw.edu
SAMPLE
DIRECTOR’S LETTER OF RECOMMENDATION TO
APPOINT CLINICAL FACULTY
Appointment letters must include the following:
• The faculty member’s teaching role (duties).
• The estimated number of hours he/she will be involved in the program annually.
• The
name and dates of medical school and residency attended.
• Board certification (specialty) and year certified.
• How faculty member meets the criteria for appointment to the recommended rank.
Date
Paul James, MD
Professor and Chair
University of Washington
Department of Family Medicine
1959 NE Pacific Avenue, Box 356390
Seattle, WA 98195
Dear Dr. James:
I recommend that (Name) be appointed as (list rank – e.g., Clinical Instructor) in the Department of
Family Medicine.
(Education Example):
(Name) graduated from the (name of institution) School of Medicine in (year) and did her/his
residency at the (name of residency) Program in (city, state) from (year) to (year) She/He was
board certified by the American Board of Family Practice in (year).
(Background Experience Example):
(Name) has served as a Family Medicine preceptor since (year) and continues to receive excellent
evaluations from her/his students. (Go on to describe the duties the clinician will be performing
and how those duties meet the criteria for appointment to the rank being requested. Specifically
indicate that the clinician meets the number of required hours teaching Family Medicine
students.
I hope that you will favorably consider (Name) for appointment to the Clinical Faculty.
Sincerely,
Program Director
UNIVERSITY OF WASHINGTON DATE OF CV
SCHOOL OF MEDICINE CURRICULUM VITAE FORMAT
The curriculum vitae should contain the following information:
1. Personal Data: Legal Name, Place of birth; citizenship, if applicable.
2. Education: University of undergraduate and graduate degrees (indicate places and dates).
3. Postgraduate Training: Internship, residencies, fellowships (places and dates).
4. Faculty Positions Held: (places and dates).
5. Hospital Positions Held: (places and dates). Do not duplicate #3 above.
6. Current Employment:
7. Honors: Phi Beta Kappa, Sigma Xi, AOA, Prizes, RCDAs, Young Investigator Awards, Teaching Awards,
etc.
8. Board Certification: General Medical and Specialty Boards (indicate date received).
9. Current License(s) to Practice: States and dates.
10. Professional Organizations: Include offices held.
11. Teaching Responsibilities: List specific courses, specific responsibility and percentage of responsibility if
shared course. Indicate role in teaching committees. List recent CME. List trainees during last 5 years, if
primary mentor.
12. Editorial Responsibilities: Include positions on editorial boards. Do not include occasional reviewing
duties.
13. Special National Responsibilities: Study sections, Training Grant Committees, American Heart Association
and other similar responsibilities.
14. Special Local Responsibilities: University and Hospital committees. Do not duplicate teaching committees
listed in #10.
15. Research Funding: Sources, dates and dollars. Include Training Grants.
16. Bibliography (use the format described in (a) for (b) through (f)):
a) First section: Manuscripts in refereed journals with authors listed in the order they appear in the original
publication. Include manuscripts in press (i.e. accepted for publication). Number these articles
consecutively and include the first and last page numbers of each article.
b) Second section: Book chapters
c) Third section: Published books, videos, software, etc.
d) Fourth section: Other publications e.g. in non-referred journals and letters to the editor.
e) Fifth section: Manuscripts submitted, listed separately with date of submission. Do not list manuscripts
in preparation or work in progress.
f) Final section: List Abstracts.
17. Other: National invitational lectures, etc.
Page 1 of 1
07/2017
WWAMI PERSONAL DATA FORM
APPLICANT INFORMATION
Legal Name:
Date of birth:
SSN:
Gender: Female Male
Address:
City:
State:
ZIP Code:
Address:
Home Work
(Please check one)
Personal Email:
CITIZENSHIP INFORMATION
Country of Citizenship:
Immigrant Status (check one):
J1 – Exchange Visitor
H1 – Working Visa
IM – Immigrant
Other (specify) _________
Date entered USA (attach photocopy
of visa):
/
month year
Date visa expires:
/
month year
University of Washington | Human Resources
Revised: 06/10/13
Employing official instructions for using the
CRIMINAL CONVICTION AND CIVIL FINDING HISTORY SELF-DISCLOSURE QUESTIONNAIRE
The offer of employment you make to the finalist candidate for a position that meets one or more of the security/safety
sensitive criteria, including positions covered by the Washington State Child and Adult Abuse Law (CAAL), must be made
contingent on obtaining a satisfactory criminal conviction background result for the candidate
(https://www.washington.edu/admin/hr/roles/mgr/hire/backgroundchk/backgroundchk-criteria.html for security/safety sensitive criteria).
After you make the contingent employment offer, you may use this form to ask the candidate to disclose potentially
disqualifying criminal convictions. After your candidate completes this questionnaire, contact your employment
specialist.
If your candidate discloses a history of criminal conviction(s), your employment specialist will assist you to determine
whether the disclosed conviction(s) disqualify the candidate from employment. If the candidate does not disclose a
potentially disqualifying conviction, your employment specialist will initiate the criminal conviction background check
process.
University of Washington | Human Resources
Revised: 06/10/13
University of Washington | Human Resources
CRIMINAL CONVICTION AND CIVIL FINDING HISTORY SELF-DISCLOSURE QUESTIONNAIRE
This questionnaire is ONLY used for those positions/appointments that are subject to a criminal conviction background check, and
are not being filled through UWHIRES. PLEASE TYPE OR PRINT RESPONSES.
The University conducts a criminal conviction background check for positions that the University has identified as security/safety sensitive,
including those covered by the Washington State Child and Adult Abuse Law (CAAL). Having a criminal conviction and/or civil finding record does
not necessarily disqualify an individual for employment at the University. However individuals with certain types of convictions or civil findings may
be ineligible for employment in some positions, as required by law. You are being asked to complete this form because you have been identified as
a qualified candidate for a position as an employee or volunteer. The information you provide will be used as part of the criminal conviction
background/civil finding review process. If you have questions about the use of conviction/criminal history information in the application process
please discuss them either with the office using this form or University of Washington Campus HR Operations 206-543-2544.
Full Legal Name Last Name, First Name Middle Name
Phone – Include area code
Email
Position or type of work for which you are applying
Date of Birth (mm/dd/yyyy)
Do you have an adult and/or juvenile criminal conviction record?
NO YES
If you answered YES, for each conviction, provide the following details:
The offense(s) Name/location of the court(s) Date(s) of the conviction(s) The sentence(s) imposed
In a civil proceeding, have you ever been found responsible for domestic violence, abuse, sexual abuse, neglect, and/or exploitation of a child or a
vulnerable adult? (Civil proceedings include noncriminal judicial or administrative hearings and determinations that have been made by agencies
such as the Department of Social and Health Services or the Department of Health). If you answer YES, you will be asked to provide details in the
next question.
NO YES
If you answered YES, for each finding, provide the following details:
Nature of finding(s) Agency/court making the finding(s) Date(s) finding(s) made Penalties/restrictions imposed
Have you ever been convicted of any crime related to the delivery of service under Medicare/Medicaid or any state or federal healthcare program,
or convicted of any crime connected with the delivery of a healthcare item or service?
NO YES
Have you ever been judged liable for civil monetary penalties for conduct related to the delivery of services, supplies or other participation in
Medicare/Medicaid or any other state or federal healthcare program?
NO YES
Have you ever been excluded from providing services or supplies under Medicare, Medicaid or any other federally-funded healthcare program?
NO YES
Have you even been subject to FDA debarment?
NO YES
If you answered YES to any of the above four questions, for each conviction, finding, or debarment, provide the following details:
Nature of finding(s)/conviction(s)/debarment Agency/court taking action Date(s) finding(s) made Penalties/restrictions imposed
I certify that the information contained in my resume and all other application-related materials I provide is true, correct, and complete. I
understand that my eligibility for employment or appointment as a volunteer is conditioned on, among other things, the University's receipt of a
satisfactory criminal conviction report and my providing proof of eligibility to work in the United States. I further understand that I can be denied
employment or discharged for any misrepresentation or omission in the information I provide. I also authorize the University of Washington to
make inquiries regarding my education, work experience, references (unless otherwise stated), and criminal conviction/civil finding history.
Signature______________________________________________________________ Date__________________
Identification and Criminal History Section
PO Box 42633, Olympia WA 98504-2633
REQUEST FOR CRIMINAL HISTORY INFORMATION
CHILD/ADULT ABUSE INFORMATION ACT
RCW 43.43.830 THROUGH 43.43.845
REQUESTING AGENCY/ADDRESS
PURPOSE
University of Washington
Check appropriate box
Agency
OMSA
Educational School District (ESD)/School District
Volunteer – no fee
Attn
8
50 Republican St.
Non-Profit Business/Organization – no fee
(Excluding Schools & ESD’s)
Address
Seattle, WA 98109
Profit Business/Organization - $17
City/State/Zip
Adoptive Parent - $17
I certify this request is made pursuant to and for the purpose indicated.
Receive background results electronically
Email address
Password (must be at least 8 characters)
Authorized Signature Date
Fees: Make payable to Washington State Patrol by check,
money order,
or business account.
Notary letters certifying the results are available
upon request (available by mail only). There is an
additional $10.00 processing fee per notary seal.
Title Area Code/Phone Number
Notarized Letter(s)
APPLICANT OF INQUIRY (Please provide as much information as possible; name and date of birth are mandatory.)
Applicant’s Name:
Last First Middle
Alias/Maiden Name(s):
Date of Birth: Sex:
Race:
Month/Day/Year
Secondary dissemination of this crimina
l history record information response is prohibited unless in compliance with statute.
WASHINGTON STATE PATROL IDENTIFICATION & CRIMINAL HISTORY SECTION
WSP Use Only
As of this date, the applicant named below has no record
pursuant to RCW 43.43.830 through 43.43.845.
Requesting Agency
Applicant’s Signature
Applicant Right Thumb Print (Optional)
Applicant’s Name
Address
City/State/Zip
3000-240-430 (R 7/11)
WASHINGTON STATE PATROL
A
B
C
D
M F
University of Washington
click to sign
signature
click to edit
acadpers@uw.edu | ap.washington.edu
Gerberding Hall 240
Final candidate name:
Last 4 digits of SSN:
Job title:
Sexual Misconduct Declaration
Washington state law and University of Washington policy prohibits UW from hiring or appointing candidates who
do not complete and sign a sexual misconduct declaration.
1.
Are you the subject of any substantiated findings of sexual misconduct in any current or past
employment?
RCW 28B.112 “Sexual misconduct, includes, but is not limited to, unwelcome sexual contact, unwelcome sexual
advances, requests for sexual favors, other unwelcome verbal, nonverbal, electronic, or physical conduct of a
sexual nature, sexual harassment, and any misconduct of a sexual nature that is in violation of the
postsecondary educational institution’s policies or has been determined to constitute sex discrimination
pursuant to state or federal law.”
Policies addressing sexual misconduct include, but are not limited to, anti-harassment and discrimination
policies and Title IX. At UW, these include Executive Orders 31, 51, 54, and 70.
☐
Yes
☐
No
2.
Are you currently being investigated for sexual misconduct at any current or past employer?
☐
Yes
☐
No
3.
Have you left a position during an investigation into a violation of any sexual misconduct policy at any
current or past employers?
☐
Yes
☐
No
If you responded “yes” to any of the questions 1-3 above, please explain the circumstances of the
finding(s) and/or investigation(s).
acadpers@uw.edu | ap.washington.edu
Gerberding Hall 240
Certification and Authorization to Release Information Regarding Sexual Misconduct
I, , hereby certify that the information above is true, complete, and accurate
to the best of my knowledge. I understand that failure to provide complete and accurate information in response to the
above questions will result in disqualification from employment or appointment at the University of Washington (UW)
and withdrawal of any offer of employment.
By my signature, I authorize any and all current and past postsecondary educational institution employers to
disclose to the UW information, if any, regarding sexual misconduct committed by me, and to make available
copies of all documents and information in the current or past postsecondary employer’s personnel, investigative,
or other files relating to any sexual misconduct, including sexual harassment, by me. I agree to execute any
additional forms required by my current or past postsecondary employer(s) to release such information to the
UW, and by my signature, I hereby release all current and past postsecondary employers from any and all claims
and liability arising from the disclosure of the information described in this paragraph.
I further authorize the UW to contact my current or past postsecondary employer(s) to verify the information that I
have provided.
Signature
Date
acadpers@uw.edu | ap.washington.edu
Gerberding Hall 240
Current and Past Postsecondary Employers
List pertinent information for all current and past postsecondary education employers, both public and
private. Attach additional pages if needed.
Employer 1
Employer name:
City/state where work was completed:
Full name when last employed:
Dates of employment:
Position held:
Department:
Explanation, if any:
Employer 2
Employer name:
Full name when last employed:
City/state where work was completed:
Dates of employment:
Position held:
Department:
Explanation, if any:
Employer 3
Employer name:
Full name when last employed:
City/state where work was completed:
Dates of employment:
Position held:
Department:
Explanation, if any:
Employer 4
Employer name:
Full name when last employed:
City/state where work was completed:
Dates of employment:
Position held:
Department:
Explanation, if any:
acadpers@uw.edu | ap.washington.edu
Gerberding Hall 240
For internal use only.
Sexual Misconduct Declaration Follow Up
To be completed by the unit administrator.
☐
Responses received; no affirmative findings
☐
No current or past postsecondary employers in Washington state
provided
☐
Listed employer(s) did not respond to information request(s)
Employers were provided the minimum five business days to respond
☐
No reference check necessary: Effective date of the Hire BP in
Workday is no further than one calendar day following the effective
date of the Termination BP
I, , hereby certify that the information above is true, complete,
and accurate to the best of my knowledge.
Unit Administrator Signature Date
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Department of Family Medicine, University of Washington CLINICAL (University of Washington)

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Completed 28 October 2021

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