Date: July 13, 2000

TO: "Division Chief"
"Division"

FROM: Mary Ann Scramstad
Coordinator for Academic Affairs
Department of Medicine

Re: Approval of Secondary Appointment for "Faculty Name"

"Dr. Name"/"Department name" has requested approval of the secondary appointment as "Rank".
As Division Chief, I am asking that you review this request. Please complete the information below:

¨ Approve of Secondary Appointment as "Rank"

¨ Disapprove of Secondary Appointment as "Rank"

Reason for Disapproval of Secondary Appointment:

________________________________________________________________________

________________________________________________________________________

Division Chief

Date

Associate Chairs' Review

This Secondary Appointment has been reviewed by the Division Chief and has been reviewed by
the Associate Chairs of the Department of Medicine.

¨ Approve of Secondary Appointment as "Rank"

¨ Disapprove of Secondary Appointment as "Rank"

Reason for Disapproval of Secondary Appointment:

________________________________________________________________________

________________________________________________________________________

The Associate Chairs reviewed this secondary appointment on: ____________________