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Personnel Data





SCHEV

James Monroe Building

101 North Fourteenth Street

Richmond, Virginia 23219




Phone: (804) 225-2600

Fax: (804) 225-2604

TDD: (804) 371-8017

Web: www.schev.edu

Instructor Qualification

^

Personnel Data


Full Name:

     

     

   

Date:

     

Last

First

M.I.

Phone:

(     )      

Work Cell #:

(     )      

Work Fax:

(     )      

E-mail Address:

     

Date of Initial Employment:

     

Full Time:



Part Time:



^ Name of School (Employer):

Virginia Tech Carilion School of Medicine

Courses that will be taught:

Problem-based learning curriculum: combination of lectures, facilitation of small team group discussions and/or clinical skills throughout the four years






Education


^ Institution Attended (Name plus city & state of location)

Graduated?

Yes No

Certificate, Diploma or Degree Earned

Major Area of Study

Dates Attended

From To

(Mo./Yr.) (Mo./Yr.)

Please see attached CV





     

     

     

     

     





     

     

     

     

     





     

     

     

     



^

Teaching and or Work Experience


Employer

     

Job Title:

     

Address:

     

Reason for Leaving:

N/A

Subject Taught :

Clinical skills

Job Duties or Responsibilities:

     

Length of Work Experience




From:

     

To:

     




Employer

Please see attached CV

Job Title:

     

Address:

     

Reason for Leaving:

     

Subject Taught:

     

Job Duties or Responsibilities:

     

Length of Work Experience:

     

From:

     

To:

     









^

Other Relevant Experience


Please see attached CV

     

Certifications/Licenses: (Attach a copy of faculty member’ credentials)





Occupational Licenses, Certifications or Registrations Held

State Issued

Expiration Date




Please see attached CV

     

     




     

     

     











^ Verification of Qualification (SCHEV regulations require faculty members to have at least one of the qualifications listed below. Indicate all the qualification that apply and attach the supporting documentation.)




^ Faculty teaching A.A.S or A.O.S level:



Associate degree in discipline being taught if teaching occupational/technical courses (attach transcript)



Baccalaureate degree plus at least 18 graduate credits in discipline being taught if teaching general education courses (attach transcripts)



Qualifies for faculty appointment by virtue of scholarly or professional achievement (attach letter from school director documenting on what basis this determination was made plus any documents that support the appointment e.g.: resume, copies of certificates held, licenses)

^ Faculty teaching on college-transfer program at the Associate level:



Baccalaureate degree in discipline being taught (attach transcript)



Baccalaureate degree plus at least 18 graduate credits in discipline being taught if teaching general education courses or in programs in the liberal arts and science (attach transcripts)



Q
^ Virginia Tech Carilion School of Medicine faculty will teach at the doctoral level (M.D.)
ualifies for faculty appointment by virtue of scholarly or professional achievement (attach letter from school director documenting on what basis this determination was made plus any documents that support the appointment e.g.: resume, copies of certificates held, licenses)

^ Faculty teaching on Baccalaureate level:



Master’s degree in discipline being taught (attach transcript)



Master’s degree plus at least 18 graduate credits in discipline being taught if baccalaureate degree is in a different discipline (attach transcripts)



Qualifies for faculty appointment by virtue of scholarly or professional achievement (attach letter from school director documenting on what basis this determination was made plus any documents that support the appointment e.g.: resume or vitae, list of scholarly publications, etc)

^ Faculty teaching on Master’s level:



Doctoral or other terminal degree in discipline being taught (attach transcript)




Qualifies for faculty appointment by virtue of scholarly or professional achievement (attach letter from school director documenting on what basis this determination was made plus any documents that support the appointment e.g.: resume or vitae, list of scholarly publications, etc)

^ Faculty teaching technical courses for career-technical programs not leading to a degree and not offered as degree credit:



Associate degree related to the area of instruction (attach transcript)



Two years of technical/occupational experience in the area of teaching responsibility (attach resume)


^

Disclaimer and Signature





I certify that the foregoing statements are true and complete to the best of my knowledge. I understand that false or misleading information may result in my release.


Signature of Applicant: _______________________________________ Date: _____________­­­___________


As an authorized school official, I have carefully reviewed and verified the qualifications of the employee and his/her statements contained on this application. To the best of my knowledge and belief, he/she is qualified for the position as required by the rules for the State Council of Higher Education for Virginia. I understand false and misleading information may result in the suspension and/or revocation of the school’s Certificate to Operate, pursuant to § 23.276.6 of the Code of Virginia.


Signature:




Date:








of
7/08




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