Faculty Information Form The information requested on this Faculty Information Form is needed for two purposes: 1) review of non-paid adjunct faculty appointments by administrative staff, the chair of the Department of Family and Preventive Medicine, and the Office of Faculty Affairs; and 2) entry of educational and other data into FacFacts, the College of Medicine’s faculty database. Adjunct appointments depend on the collection of this information.Please upload a copy of your resume/CV (updated within 6 months).(Required)Max. file size: 15 MB.In which of the following activities will you be participating?(Required) Resident Precepting Student Precepting At which of the following locations are you requesting a non-paid adjunct appointment?(Required) Batesville (North Central Regional Campus) Berryville-Eureka Springs Rural Track Program Crossett Rural Track Program Fayetteville-Springdale (Northwest Regional Campus) Fort Smith (West Regional Campus) Helena (East Regional Campus) Jonesboro (Northeast Regional Campus) Magnolia (South Regional Campus) North Little Rock (Baptist Health–UAMS Family Medicine Residency) Pine Bluff (South Central Regional Campus) Texarkana (Southwest Regional Campus) Other Faculty ProfileFirst Name(Required)Middle InitialLast Name(Required)Degree(Required) MD DO MPH Other If you selected Other, please list here.(Required)Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Spouse/Partner Name First Last Preferred Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business Phone(Required)Mobile Phone(Required)I consent to receive text messages related to processing and renewing this non-paid adjunct appointment.(Required) Yes No Preferred Email(Required) EducationMedical School(Required)City(Required)State(Required)Country(Required)Degree Earned(Required)Year Degree Earned(Required)Residency Program(Required)City(Required)State(Required)Country(Required)Year Residency Completed(Required)Medical LicensureAre you licensed to practice medicine in the state of Arkansas?(Required) Yes No Is your Arkansas Medical license currently active?(Required) Yes No Board CertificationAre you board certified?(Required) Yes No What is your primary board certification?(Required) Emergency Medicine Family Medicine Internal Medicine Obstetrics and Gynecology Orthopaedic Surgery Pediatrics Other If you selected Other, please list here.(Required)What is your secondary board certification, if any?Annual Activities DescriptionAttestation of Prospective Adjunct FacultyPlease check each box showing your agreement to the statements:Medical students and faculty will have access to appropriate resources for medical student education.(Required) I agree UAMS College of Medicine is responsible for the medical education program, academic affairs, and assessment of medical students.(Required) I agree UAMS College of Medicine is responsible for the appointment and assignment of faculty members with responsibility for medical student teaching.(Required) I agree In case of student exposure to an infectious or environmental hazard or other occupational injury, treatment and follow-up should follow the UAMS Medical Center policies.(Required) I agree I will partner with UAMS College of Medicine to share responsibility for creating and maintaining an appropriate learning environment, conducive to learning and safety.(Required) I agree I understand that my adjunct faculty appointment requires a minimum of 20 hours of service annually to AHEC/Regional Campuses and UAMS College of Medicine. I agree to provide that service during my adjunct appointment.(Required) I agree Signature(Required) Full Name Date(Required) MM slash DD slash YYYY
