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<html>
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<script language="JavaScript" src="../../js/forms.js"></script>
<script language="javascript">
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<title>FORM 1-a   <a name="TITLENAME"></a></title>
</head>
<body bgcolor="#FFFFFF" class="Normal" lang="EN-US">
<div class="Section1">
<p align="center" style='text-align: center'>
<b><u>UNIVERSITY CURRICULUM VITAE FORMAT (SN/SHRP)</u></b><br>
<p><b>Date:</b> <u><a name="CVFORMAT_DATE"></a></u></p>
<p><b>NAME:</b> <u><a name="CVFORMAT_NAME"></a></u></p>
<p><b>PRESENT TITLE:</b> <u><a name="CVFORMAT_PRESENT_TITLE"></a></u></p>
<p><b>HOME ADDRESS:</b> <u><a name="CVFORMAT_HOMEADDRESS"></a></u></p>
<p><b>OFFICE ADDRESS:</b> <u><a name="CVFORMAT_OFFICEADDRESS"></a></u></p>
<p><b>HOME OR CELL TELEPHONE NUMBER:</b> <u><a name="CVFORMAT_TELEPHONENUMBER"></a></u></p>
<p><b>E-MAIL ADDRESS:</b> <u><a name="CVFORMAT_EMAIL"></a></u></p>
<p><b>CITIZENSHIP:</b> <u><a name="CVFORMAT_CITIZENSHIP"></a></u></p>
<p><b>EDUCATION:</b> <i>(chronological order)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('CVFORMAT_EDUCATION_UNDERGRADUATE_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Undergraduate</a>
</p>
<p><a name="CVFORMAT_EDUCATION_UNDERGRADUATE"></a></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('CVFORMAT_EDUCATION_GP_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Graduate and Professional</a>
</p>
<p><a name="CVFORMAT_EDUCATION_GP"></a></p>
<p><b>POST DOCTORAL or ADDITIONAL TRAINING:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('CVFORMAT_EDUCATION__LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Type</a>
</p>
<p><a name="CVFORMAT_EDUCATION_GP"></a></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Location </a>
</p>
<p><b>EMPLOYMENT/WORK EXPERIENCE:</b> <i>(chronological order)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Inclusive Dates</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Title </a>
</p>
<p><b>MILITARY:</b></p>
<p><b>ACADEMIC APPOINTMENTS:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Department</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">University (School of Medicine) </a>
</p>
<p><b>HOSPITAL APPOINTMENTS:</b> <i>(If applicable)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Department</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Hospital Name </a>
</p>
<p><b>LICENSURE:</b> <i>specialty/#/inclusive dates</i></p>
<p><b>CERTIFICATION:</b> <i>specialty/#/inclusive dates </i></p>
<p><b>DRUG LICENSURE:</b> <i>(If applicable)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">CDS:<i>#/inclusive dates</i></a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">DEA:<i>#/inclusive dates</i></a>
</p>
<p><b>HONORS AND AWARDS:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Title</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Awarded By</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Date</a>
</p>
<p><b>MEMBERSHIPS, OFFICES AND COMMITTEE ASSIGNMENTS IN PROFESSIONAL SOCIETIES:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Name of Organization</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Member or other Position</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">Inclusive Dates</a>
</p>
<p><b>BOARDS OF DIRECTORS/TRUSTEES POSITIONS (excluding professional societies that are above):</b></p>
<p><b>SERVICE ON NATIONAL GRANT REVIEW PANELS, STUDY SECTIONS, COMMITTEES:</b></p>
<p><b>SERVICE ON JOURNALS/PUBLICATIONS:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">A. Editorial Boards <i>(Journal Name, Inclusive Dates)</i></a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">B. AdHoc Reviewer <i>(Journal Name, Inclusive Dates)</i></a>
</p>
<p><b>SERVICE ON INSTITUTIONAL COMMITTEES: </b></p>
<p><b>SERVICE ON SCHOOL COMMITTEES:</b></p>
<p><b>SERVICE ON UNIVERSITY DEPARTMENT/PROGRAM COMMITTEE:</b></p>
<p><b>SERVICE TO THE COMMUNITY:</b></p>
<p><b>SPONSORSHIP OF STUDENTS FOR UNDERGRADUATE RESEARCH:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;"><i>Title; inclusive dates; names of students; your role</i></a>
</p>
<p><b>SPONSORSHIP of MASTER’s THESIS/PROJECTS:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;"><i>Title; inclusive dates; names of students; your role</i></a>
</p>
<p><b>DISSERTATION CHAIR, COMMITTEE MEMBER, REVIEWER:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;"><i>Title; inclusive dates; names of students; your role</i></a>
</p>
<p><b>SPONSORSHIP OF POSTDOCTORAL FELLOWS:</b></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;"><i>Inclusive dates; names of students; your role</i></a>
</p>
<p><b>TEACHING RESPONSIBILITIES: </b><i>(for each School if not primary appointment, course name, credits or hours)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">a. Curriculum Design </a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">b. Primary Instructor </a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">c. Co-Instructor</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">d. Lecturer</i></a>
</p>
<p><b>CLINICAL RESPONSIBILITIES: </b></p>
<p><b>GRANT SUPPORT:</b><i>(Please list in either chronological order with newest or most current first OR in reverse chronological order, as desired)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">A. Principal Investigator</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">B. Co-Investigator</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">C. Pending Grants</a>
</p>
<p><b>OTHER SCHOLARSHIP/RESEARCH PUBLICATIONS:</b><i>(Please list in either chronological order with newest or most current first OR in reverse chronological order, as desired (no numbers); published or accepted for publication only; should be segregated into the following categories)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">A. Refereed Original Article in Journal<i>(include if research or major review)</i></a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">B. Books, Monographs and Chapters</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">C. Other Articles (Reviews, Editorials, etc.) In Journals; other Professional Communications</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">D. Abstracts</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">E. Reports</a>
</p>
<p><b>PRESENTIONS:</b><i>(Please list in either chronological order with newest or most current first OR in reverse chronological order, as desired)</i></p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">A. Scientific<i> (Basic Science):</i></a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">B. Original Research</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">C. Professional Education</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">D. Abstracts</a>
</p>
<p style="margin-left: 50px">
<a href="javascript:OnClick('DOCT_PRIM_THESES_SUPERVISED_LINK_TO_FACSURV');" style="COLOR: Black; TEXT-DECORATION: none; CURSOR: hand;">E. Other</a>
</p>
<p><b>PATENTS HELD:</b></p>
</div>
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