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Applicant Form

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Clinical Faculty Application

To initiate an academic appointment at the New York Institute of Technology College of Osteopathic Medicine, please complete and the following application. You will be considered clinical faculty only upon receipt of a letter and certificate from NYITCOM indicating your appointment.

The following will be needed for this application:

Clinical Faculty Application		For Non-Licensed Residents
An updated copy of your curriculum vitae A copy of your medical school diploma A copy of your medical license and/or current medical registration A copy of your current Board Certification The signed Clinical Faculty Application (via online application)		An updated copy of your curriculum vitae (include your current residency) A copy of your medical school diploma Documentation showing that you are enrolled in a ACGME approved residency A signed letter from the program director of the department you will be working in indicating the licensed doctor supervising you The signed Clinical Faculty Application (via online application)

This application is enabled to allow 'Save & Return Later' option which allows respondents to leave the survey and return later. A return code is will be provided and is *required* in order to continue the survey where you left off.

Questions? Please email comfacappt@nyit.edu for assistance.

Which NYIT College of Osteopathic Medicine campus are you applying to?

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This form is pre-filled with information from your previous appointment. Please review it carefully and ensure all fields are accurate and up to date. You may edit any field as needed to provide the most current information.

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I Understand

Please indicate application type:

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Select option that applies:

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Hospital Affiliated Adjunct Clinical Faculty

Office Preceptor Adjunct Clinical Faculty

Hospital Affiliates and Office Preceptors

Please indicate which location will be your primary site while working with NYITCOM students:

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Are you a Non-Licensed Resident?

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Yes

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Will you be uploading a Medical License?

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Yes

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Are you a site coordinator submitting this information on behalf of a preceptor?

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Yes

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Site Coordinator Name: (first_last)

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Site Coordinator Email:

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Applicant First Name:

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Applicant Last Name:

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Applicant Street Address:

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Applicant City:

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Applicant State:

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Applicant Zip code:

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Applicant Personal Email:

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Applicant Cell Phone:

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Applicant Gender:

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Applicant DOB:

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M-D-Y

Applicant Medical Degree:

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Degree Granting Med. Institution (Include City and State):

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Graduation Year:

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Practice Specialty:

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If, "other" add specialty here:

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If you have a subspecialty, please enter it here.

Board Certified:

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Board Certified Current Specialties:
(Please indicate organization ie. ABP, ABPN, etc.)

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Recertification Year:

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Current (Other) Medical School Appointments
(School, Rank):

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Current Hospital Name:

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Hospital Address:

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Hospital City:

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Hospital State:

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Hospital Zip Code:

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Do you have an additional contact at the hospital you would like to enter on the application?

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Yes

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Contact at Hospital Name (first_last):

Contact Title/Position:

Contact Email:

Contact Phone:

Contact Fax:

Office/Clinic Name:

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Office/Clinic Address:

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Office/Clinic City:

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Office/Clinic State:

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Office/Clinic Zip Code:

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Office/Clinic Email:

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Office/Clinic Phone:

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Office/Clinic Fax:

Do you have an Office/Clinic Contact you would like to add?

Yes

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Office/Clinic Contact Name: (first_last)

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Office/Clinic Contact Email:

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Has your license ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited, sanctioned, placed on probation, monitored, or not renewed for any reason?

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Yes

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Have you ever been subject to review, challenges, disciplinary action, formal or informal, by an ethics
committee, licensing board, medical disciplinary board, professional association or education/training
institution?

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Yes

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Have you been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions?

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Yes

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Have you ever been the subject of any reports to a state, federal, national data bank, or state licensing or disciplinary entity?

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Yes

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Have you ever been charged with, or have notice of anticipated charges of a criminal violation (felony or misdemeanor) resulting in either a plea bargain, conviction on the original or lesser charge, or payment of a fine, suspended sentence, community service or other obligation?

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Yes

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Do you have any pending malpractice incidents, or have you had any arbitrated, mediated or litigated malpractice actions within the past 7 years?

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Yes

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If you answered "Yes" to any of the questions above, please provide a brief explanation here:

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If you answered "Yes" to any of the questions above, you may upload documentation here:
(optional)

Upload file

I attest that all statements made on this form and on any attached documentation are complete, accurate and current. I understand that any material misstatements in, or omissions from, this statement constitute cause for denial of application, or faculty suspension/dismissal from New York Institute of Technology College of Osteopathic Medicine.
My typed signature is my symbol of authentication where I willingly validate and endorse this document

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Add signature

Attestation Date:

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M-D-Y

This University is an Equal Opportunity Employer and the information requested here is not included as part of the application process. Providing this information is voluntary and confidential. A decision not to provide this information will not result in any adverse treatment of your application. It is an unlawful employment practice for an employer to fail or refuse to hire, promote or discharge any individual, or otherwise to discriminate against an individual with respect to that individual's terms and conditions of employment, based on individual's race, sex, marital status, color, religion, national origin, sexual orientation, physical/mental disability or condition, or age (except for those less than 13) as defined by state and federal laws and regulation, except when bona fide occupational qualifications exist that restrict or exclude applicants based on that bona fide occupational qualification.

Race/Ethnicity: Please select one of the descriptions below corresponding to the ethnic group with which you most identify.

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Hispanic or Latino: a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North African.

Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America) who maintains tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino): all persons who identify with more than one of the above five races.

I do not wish to complete this self-identification.

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Please check each activity item that is applicable to your teaching role:

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Present lectures to students and/or residents

Clinical supervision in a private practice of students and/or residents

Clinical supervision in a hospital of students and/or residents

Rounding in hospital with students and/or residents

Other

Please indicate Other activity:

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Curriculum Vitae (CV): To be considered for an Adjunct Clinical Faculty Appointment, your CV must be provided. Please upload your CV here.

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Upload file

Medical School Diploma: To be considered for an Adjunct Clinical Faculty Appointment, your medical school diploma must be provided. Please upload your medical school diploma here.

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Upload file

Board Certified: To be considered for an Adjunct Clinical Faculty Appointment, please upload proof of your Board Certified status.

Upload file

ACGME approved residency: To be considered for an Adjunct Clinical Faculty Appointment, you must provide documentation showing that you are enrolled in a ACGME approved residency. Upload your supporting documentation here.

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Upload file

Program Director Letter: To be considered for an Adjunct Clinical Faculty Appointment, you must provide a signed letter from the program director of the department you will be working in indicating the licensed doctor supervising you.

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Upload file

I affirm that I am duly licensed to practice medicine, and have current medical malpractice insurance. I will notify the Associate Dean of Academic Affairs immediately of any changes to my practice status. I agree that either party will provide the other with at least a 90 day notice, should either decide to voluntarily terminate a clinical faculty appointment. This agreement may be terminated, with cause, at any time by NYITCOM.

Upon the completion of each individual training period, I will, if required, fully complete and return to NYITCOM, within 14 days, a performance evaluation for each of my students. Each student completing a rotation with me will complete a faculty evaluation form; such student evaluations of faculty are part of an ongoing process.

I hereby grant permission to the New York Institute of Technology to use my name in official university publications. Such official university publications may include printed materials, websites, videos, and advertisements.

With this application, I seek appointment as Clinical Faculty to provide clinical training for the NYITCOM medical students. I agree to follow the curriculum provided by the Office of Academic Affairs at NYITCOM and also agree to review, monitor, and provide feedback for the revision of the curriculum as needed and/or as requested by the Office of Academic Affairs. I understand and agree to keep student and other NYITCOM related information confidential and disclose such information only to authorized NYITCOM personnel.

With my signature, I attest the information provided in this application to be true.
My typed signature is my symbol of authentication where I willingly validate and endorse this document

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Add signature

Signature Date:

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M-D-Y

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