Request for Without Salary (WOS) Appointment

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Your answers on this survey will assist us in identifying the appropriate type of academic appointment for which you qualify. When your completed survey is received, we will contact you to provide additional documentation as part of your complete application.

Email *

First and Last Name *

Employer *

Employer Mailing Address *

Are you board-certified in Pediatrics? *

Yes

Please enter your board certification area or enter "N/A" *

Indicate the area(s) of Pediatrics in which you practice/teach. Select all that apply: *

General Pediatrics

Adolescent Health and Medicine

Blood and Marrow Transplantation

Cardiology

Clinical Neuroscience

Critical Care Medicine

Emergency Medicine

Endocrinology

Epidemiology and Clinical Research

Gastroenterology, Hepatology, Nutrition

Genetics and Metabolism

Global Pediatrics

Hematology/Oncology

Hospital Medicine

Infectious Diseases

Neonatology

Nephrology

Pulmonary Medicine

Rheumatology

Other:

Required

Do you have a previous affiliation with the University of Minnesota (student, resident, fellow, faculty, staff, etc.)? *

Yes

Select the response below that best describes how you meet the initial criteria for an academic appointment: *

I am a pediatrician or advanced practice provider in a clinical setting (either inpatient or outpatient) who educates medical students, residents, fellows, or allied health care professionals.

I am a pediatrician or advanced practice provider whose primary employment is with a hospital affiliated with the University of Minnesota (UMMCH, Children's, Hennepin Healthcare, Gillette)

I am a faculty member at another academic institution who collaborates with faculty at the University of Minnesota.

I am an external investigator or medical provider and/or an advocate for children with local and state government agencies.

I have a principle occupation in an industry-related profession who contributes to the University of Minnesota through research and/or teaching.

I am a University of Minnesota faculty member who holds an appointment outside of the Department of Pediatrics (i.e. School of Public Health, Department of Surgery, School of Nursing, etc.)

Other:

Are you currently teaching University of Minnesota medical students, residents, fellows, or other allied health care professionals? *

Yes

If "Yes", are your teaching contributions reaching or exceeding 100 hours per calendar year? *

Yes

Maybe

N/A

Please describe the teaching activities you are currently involved in, including the approximate number of hours you devote to teaching trainees. If you are not currently involved in teaching, please enter "N/A" *

In order to maintain an active adjunct faculty appointment with the Department of Pediatrics you must teach a minimum of 100 hours per year. Please describe your anticipated involvement in education below. *

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