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:  ____________________