Full Legal Name*
First, Middle, and Last Legal Names
Licenses*
Medical or other. If none, please write "none."
Certifications*
If none, please write "none."
Email Address*
Your preferred email address
Phone Number*
Your preferred phone number
Home Address*
Street, City, State, and Postal Code
Current Place of Employment*
Current Place of Employment
Address of Place of Employment*
Street, City, State, and Postal Code
Taught medical students and residents at UNC PM&R, during your current appointment*
Please provide number of students, learning topics, and frequency of your teaching. If you did not teach, please write "no."
Supervised a medical student or resident's clinical work at UNC PM&R, during your current appointment*
Please provide details of clinical work involved and time spent. If you did not supervise a medical student or resident, please write "no."
Collaborated on Research through grants or papers within UNC PM&R, during your current appointment*
Please provide name of the research project, other involved faculty members, and time spent. If you did not collaborate on research through grants or papers, write "no."
Served as a consultant on any research project within UNC PM&R, during your current appointment*
Please provide your consulting details, other involved faculty members, and time spent. If you did not serve as a consultant on a research project, write "no."
Your statement*
Write a brief statement (3-7 sentences) as to how your UNC PM&R Adjunct Appointment has served you.
Engagement*
If granted a reappointment within our department, are there other ways that you plan to engage with our department over the next two years? If so, please describe. If no, please write "none."
