Date:    May 7, 2003

TO:                  «First_Name» «Last_Name», «Degree»«Address»
«Address2»
«Address3»
«City», «ST»   «ZIP»

Re:                   Renewal of Secondary Appointment as «Secondary_Rank»

Please indicate your desire in renewing your appointment for another three years. If you are involved with teaching medical students and/or residents for the Department of Medicine, you are required to have a faculty appointment.

`  NO, I do not wish to renew my faculty appointment. Please remove my name from your rosters. Please sign here and date.

___________________________________
«First_Name» «Last_Name», «Degree»

`  Yes, I do want to renew my Secondary faculty appointment as «Secondary_Rank»

In the past 3 years I have participated in the Department of Medicine's Medical Education Programs in the following areas.

`  I supervised Internal Medicine ¨ students, ¨ residents and/or ¨ fellows in outpatient offices during the following months:___________________________________

`  I supervised Internal Medicine ¨ students, ¨ residents and/or ¨ fellows in the care of inpatients

`  I taught Internal Medicine ¨ students, ¨ residents and/or ¨ fellows in the classroom (e.g., lecture or small group preceptor)

`  I gave Department of Medicine Grand Rounds or noon conference presentations

`  I was a regular participant in Department of Medicine journal clubs and/ or case conferences

`  I participated in research with (Creighton faculty) _________________________ on _________________________________

`  Other contributions ___________________________________________
                                          ^{(Please List Examples)}

___________________________________
«First_Name» «Last_Name», «Degree»

 

Please provide a current CV in preparation of your reappointment: