Application Information

First Name 

Last Name

Degree(s) 

Email

With which area do you most identify?

• Medicine
• Nursing
• Dentistry

Academic Rank

Primary Department  

Current Primary Division [If applicable.]

Current Education-Related Role(s) [If applicable.]

As an Educator, What Do You Consider to Be Your Strengths? [Select all that apply.]

• Advising and/or Mentorship
• Curriculum Development
• Education Leadership and/or Administration
• Evaluation and/or Assessment
• Observation and/or Providing Feedback
• Teaching
• Other (please describe)

As an Educator, In What Areas Would You Like to Develop Further Skills? [Select all that apply.]

• Advising and/or Mentorship
• Curriculum Development
• Education Leadership and/or Administration
• Evaluation and/or Assessment
• Observation and/or Providing Feedback
• Teaching
• Other (please describe)

Statement of Educational Philosophy Describe your approach to education, supported by educational principles that underlie your teaching and your experience with how people learn. What are your strengths as an educator? Provide examples. [This section should be a maximum of 500 words, or 3000 characters.]

Describe Your Educational Innovation This is your chance to brag a bit. Tell us about one (1) educational innovation that you are proud of. Explain how what you have done is creative and/or how you are innovative as an educator. Examples could be a series of workshops, curriculum on current topics, novel assessment tool, integration of AI into an educational practice, etc. [This section should be a maximum of 500 words, or 3000 characters.]

Share Your Educational Innovation *ENCOURAGED*  If you would like to upload an example of your educational innovation, please do so here. Additional content may include a brief video, sample curriculum development, examples of assignments, or something else that demonstrates your work. Whatever you choose to upload must be 100MB or less. [This is not required, but encouraged!]

In this section, you will describe up to three (3) activities that are typical of your teaching and for which you are best able to demonstrate variety, quantity, quality, and impact. This section should not be a comprehensive list as presented on your CV. [Limit to 3 activities; additional space will appear as you fill in teaching information.]

Is There a Teaching Activity That You Would Like to Highlight?

• Yes
• No

Is This Activity Your Educational Innovation (Highlighted in the First Section of This Application)?

• Yes
• No

Teaching Activity (#1)

• Title of Teaching Activity
• Teaching Strategy & Context (ex. fellowship seminar with interactive discussion, faculty workshop with small group activities, precepting with rounds and bedside teaching, brief talks, discussion, etc.)

Total Teaching Time (#1)

• Fewer than 10 hours per year
• 10-40 hours per year
• More than 40 hours per year

Type of Teaching Activity (#1) [Select all that apply.]

• Case Conference
• Clinical Precepting
• Lecture / Grand Rounds
• Panel Discussion
• Problem-Based Learning Seminar
• Small Group Discussion
• Team-Based Learning Workshop
• Other (please describe)

Type(s) of Learners Impacted by Teaching Activity (#1) [Select all that apply.]

• Students – dental
• Students – medical
• Students – nursing (prelicensure)
• Students – NP
• Students – PA
• Students – pharmacy
• Students – undergraduate or graduate students
• Residents – MD / DO
• Residents – dental
• Fellows – MD / DO
• Fellows – NP
• Fellows – PA
• Faculty – dental
• Faculty – medical
• Faculty – nursing
• Other (please explain)

Location of Teaching Activity (#1) [Select all that apply.]

• Departmental
• Institutional
• Regional
• National
• International

The application will then ask if you have second and/or third Teaching Activities you would like to highlight. If you select Yes, the questions above will repeat.

If you shared any teaching activities, the application will prompt you to answer the following:

Evaluation of Teaching Activities Briefly summarize results from learner evaluations from your list of teaching activities above. [Limit to 125 words, or 800 characters.]

Materials for Evaluation of Teaching Activities *OPTIONAL* You may upload teaching evaluations and peer evaluations directly.

Quality and Impact of Teaching Activities Describe the importance, creativity, innovation, quality and impact of the teaching activities included above. How did the teaching activities change your educational practice? Describe evidence that you used evidence-based principles of teaching and learning. [Limit to 200 words, or 1200 characters.]

Evidence of Scholarship in Teaching List/describe products of educational scholarship that were peer-reviewed, presented, published or adapted for use in other programs as a result of your teaching activities. [Limit of 3 products.]

In this section, you will describe up to 3 examples of how you contributed to learner assessment (e.g., tool development, analysis of results, etc.). These learner assessments may be for the Teaching Activities you listed in the previous section. You may also include learner assessments you developed for other instructors and/or programs that you have not yet included. [Limit of 3 activities; additional space will appear as you fill in assessment information.]

Is There an Assessment Activity That You Would Like to Highlight?

• Yes
• No

Is This Activity Your Educational Innovation (Highlighted in the First Section of This Application)?

• Yes
• No

Learner Assessment Activity (#1)

• Title of Assessment Activity
• Number of Learners Assessed (per year)

Learner Assessment Method (#1) [Select all that apply.]

• Chart audit
• Clinical decision-making exam
• Direct observation of learner
• Essay test
• Multiple choice question test
• Oral exam
• OSCE
• Script concordance test
• Short answer test
• Simulation
• Other (please explain)

Types of Learners Assessed (#1) [Select all that apply.]

• Students – dental
• Students – medical
• Students – nursing (prelicensure) 
• Students – NP
• Students – PA
• Students – pharmacy
• Students – undergraduate or graduate
• Residents – MD / DO
• Residents – dental
• Fellows – MD / DO
• Fellows – NP
• Fellows – PA
• Faculty – dental
• Faculty – medical
• Faculty – nursing
• Other (please explain)

My Role in Learner Assessment (#1) [Select all that apply.]

• Contributor / Assessor
• Leader / Developer
• Other (please explain)

Location of Learner Assessment (#1) [Select all that apply.]

• Departmental / Institutional
• Regional / National / International

Level of Assessment Based on Miller's Pyramid of Skill Development (#1)

• Knows
• Knows how
• Shows how
• Does

The application will then ask if you have second and/or third Assessment Activities you would like to highlight. If you select Yes, the questions above will repeat.

If you shared any assessment activities, the application will prompt you to answer the following:

Quality and Impact of Learner Assessment Activities Describe the importance, creativity, innovation, quality and impact of the learner assessment activities included in the section above. How did the information obtained through your assessments change your educational practice? Describe evidence that you used a scholarly approach and/or addressed validity issues. [Limit to 200 words, or 1200 characters.]

Evidence of Scholarship in Assessment List/describe any products of educational scholarship that were peer-reviewed, presented, published or adapted for use in other programs as a result of your assessment activities. [Limit of 3 products.]

In this section, you will share up to 3 examples of how you approached the development of curricula implemented by yourself or others. If applicable, curricula development may be for the Teaching Activities you listed in the previous section. [Limit of 3 activities; additional space will appear as you fill in curricular information.]

Is There an Example of Curriculum Development That You Would Like to Share?

• Yes
• No

Is This Example Your Educational Innovation (Highlighted in the First Section of This Application)?

• Yes
• No

Curricular Activity (#1)

• Title of Curricular Activity
• Type of Curricular Activity (clerkship lecture, online module, program-wide curriculum, etc.)
• Number of Learners Assessed (per year)

Types of Learners Assessed (#1) [Select all that apply.]

• Students – dental
• Students – medical
• Students – nursing (prelicensure) 
• Students – NP
• Students – PA
• Students – pharmacy
• Students – undergraduate or graduate
• Residents – MD / DO
• Residents – dental
• Fellows – MD / DO
• Fellows – NP
• Fellows – PA
• Faculty – dental
• Faculty – medical
• Faculty – nursing
• Other (please explain)

Location of Curricular Activity (#1) [Select all that apply.]

• Departmental / Institutional
• Regional / National / International

My Role in This Curricular Activity (#1) [Select all that apply.]

• Contributor / Collaborator
• Leader
• Other (please explain)

The application will then ask if you have second and/or third Curriculum Development Activities you would like to highlight. If you select Yes, the questions above will repeat.

If you shared any curricular activities, the application will prompt you to answer the following:

Quality and Impact of Curriculum Development Activities Choose one curriculum from the examples you listed above as an example of your best effort, then describe your process of curriculum development. You may do some by incorporating a specific framework, such as GNOME or Backward Design. [Limit to 200 words, or 1200 characters.]

Evidence of Scholarship in Curriculum Development List/describe any products of educational scholarship that were peer-reviewed, presented, published or adapted for use in other programs as a result of your curriculum development activities. [Limit of 3 products.]

In this section, you will provide details of your most significant mentoring/advising activities. This section should not be a comprehensive list of all the mentoring/advising activities presented on your CV. Instead, highlight the relationships for which you had the most significant role. [Limit of 5 individuals; more boxes will appear as you fill in mentee information.]

Is There a Mentee You Have Worked With Who You Would Like to Highlight? 

• Yes
• No

Mentee Information (#1)

• Mentee Name
• Mentoring Period (please provide time frame of mentorship)
• Mentee Position at time of Mentorship
• Mentee Current Position
• Mentee Achievements

Mentee Relationship (#1) [Select all that apply.]

• Student Advisor
• Near Peer Mentor
• Research Mentor
• Career Development Mentor
• Other (please describe)

The application will then ask if you have up to four additional Mentees you would like to highlight. If you select Yes, the questions above will repeat.

If you shared any mentorship or advising activities, the application will prompt you to answer the following:

Mentorship & Advising Philosophy Describe your mentoring philosophy and the process by which you typically mentor professionals. [Limit to 200 words, or 1200 characters.]

Quality and Impact of Mentoring & Advising Activities Describe the importance, creativity, innovation, quality, and impact of the mentoring/advising activities described in the above section. How has the information obtained through your mentoring/advising activities changed your educational practice? Describe evidence that your mentoring/advising activities have been developed using a scholarly approach. [Limit to 200 words, or 1200 characters.]

Evidence of Scholarship in Mentorship & Advising List/describe any products of educational scholarship that were peer-reviewed, presented, published or adapted for use in other programs as a result of your mentorship and/or advising activities. [Limit of 3 products.]

In this section, you will provide details of your most significant leadership activities. [Limit each section to 3 activities; additional space will appear as you fill out the sections.]

Is There a Course or Program That You Direct That You Would Like to Highlight?

• Yes
• No

Course or Program I Direct (#1)

• Title of Course or Program that I Direct
• Overview of Activities (please provide a brief description)

Years Involved (#1)

• 0-2 years
• 3-5 years
• 6-10 years
• 10+ years

Location of Course or Program I Direct (#1) [Select all that apply.]

• Departmental
• Institutional
• Regional
• National
• International

The application will then ask if you have up to two additional Courses or Programs That You Direct that you would like to highlight. If you select Yes, the questions above will repeat.

Is There an Educational Committee That You Direct or Chair That You Would Like to Highlight?

• Yes
• No

Educational Committee That I Direct or Chair (#1)

• Title of Educational Committee that I Direct or Chair
• Overview of Activities (please provide a brief description)

Years Involved (#1)

• 0-2 years
• 3-5 years
• 6-10 years
• 10+ years

Location of Educational Committee That I Direct or Chair (#1) [Select all that apply.]

• Departmental
• Institutional
• Regional
• National
• International

The application will then ask if you have up to two additional Educational Committees That You Direct or Chair that you would like to highlight. If you select Yes, the questions above will repeat.

Is There an Educational Committee of Which You Are a Member That You Would Like to Highlight?

• Yes 
• No

Educational Committee of Which I am a Member (#1)

• Title of Educational Committee of which I am a Member
• Overview of Activities (please provide a brief description)

Years Involved (#1)

• 0-2 years
• 3-5 years
• 6-10 years
• 10+ years

Location of Educational Committee of Which I am a Member (#1) [Select all that apply.]

• Departmental
• Institutional
• Regional
• National
• International

The application will then ask if you have up to two additional Educational Committees of Which You Are a Member that you would like to highlight. If you select Yes, the questions above will repeat.

If you shared any mentorship or advising activities, the application will prompt you to answer the following:

Quality and Impact of Leadership Activities Choose one program from the above list as an example of your best effort. Describe the program and its impact. Provide evidence of the scholarly approach you took in this leadership role. [Limit to 200 words, or 1200 characters.]