Clinical Faculty Application

Required *

First Name *

This field cannot be empty

Last Name *

Email *

Ethnic Background

The University of Hawai‘i complies with recordkeeping requirements under federal and State civil rights laws and regulations. In accordance with these laws, the University invites employees to voluntarily self-identify their sex and race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations.

Are you Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origini regardless of race)?

Please select one or more racial categories to describe yourself:

Documents:

Application will not go to Committee until all documents are received.

--Curriculum vitae and bibliography updated within 1 year

--Current copy of medical license

--Copy of certificate(s) of Board(s) Certification

--Completed I-9 Form with necessary supporting documents (please mail orginial form to the address below).

--Current TB Clearance (must be a skin test or chest x-ray report, if positive)

Please upload these forms (PREFERRED) or mail them in.

Address:

Julieta Rajlevsky

UH Department of Medicine

1356 Lusitana St., 7th Floor

Honolulu, HI 96813

The Department of Medicine requires 2 letters of recommendation (addressed to the Chairman) as part of the Clinical Faculty application. Please provide the names and contact information of two professional references below:

Curriculum Vitae:

Copy of Medical License

Copy of Certificates of Board(s) Certification:

Current TB Clearance or Chest X-Ray Report:

Any Additional Documents

My previous appointment was: *

I agree to spend 60 hours in each calendar year in formal teaching activities. *

Use CTRL + click to select multiple activities

These 60 hours may be spent in the following ways (please check all that you wish to participate in):

Please write the name of the Student/Resident Elective here:

I have read the guidelines for appointments to the Clinical Faculty and wish to remain or become a member of the Clinical Faculty. *

Guidelines for Appointment to Clinical Faculty

Questions?

If you have any questions, please call Julieta Rajlevsky at 808-586-7478 or email her at jlrajlev@hawaii.edu.

Also, you can leave any comments you have here:

Comments:

Type your full name below, which will be your Signature on this form: *