DEMOGRAPHIC INFORMATION

Current Appointments
University; Hospital; Other

Personal Data
Business Address, phone, fax, e-mail

Education and Training (in chronological order)
Degrees/Year | Institution | Discipline
Undergraduate
Doctoral/graduate
Postdoctoral - (internship, residency, fellowship etc.)

Professional Experience (in chronological order)
Dates | Positions | Institutions

Publications (include only those published or in press; do not include submitted, in preparation, or planned)

Please show all authors for all articles and chapters

Please bold or underline your name as an author in each reference

Please list all articles chronologically from earliest to latest.

Please number all articles consecutively under each section.

Please use standard reference citation format: example:

Author FI, Secondauthor FI, Thirdauthor FI. Title. Journal. Year; Volume (Number): page-page.

Please separate publications into the following categories:

Peer-reviewed original research articles

Review articles

Editorials

Letters, correspondence

Book Chapters, Monographs

Books, Textbooks

Other media (films, videos, CD-ROMs, slide sets, etc)

Inventions, Patents, Copyrights (pending, awarded)
Date | Title

Extramural Sponsorship (current, pending, previous)

For each grant or contract please provide: dates, title, identification number, sponsor, total direct cost, current year direct cost, principal investigator, your role,your percent effort

Grants

Contracts

Other

Teaching

Classroom instruction (course title, dates, role)

Clinical instruction (service, dates, role)

CME instruction (course title, dates, role)

Mentoring (pre- and post-doctoral)

Advisees (provide: name, dates, degree, present position, awards/grants/degrees received under your direction)

Thesis committees (provide: name, title, dates, your role)

Training grant participation (provide: program name, dates, your role)

Editorial Activities

Editorial Board appointments

Journal peer review activities

Certification

Medical, other state/government licensure (date, identification#)

Boards, other specialty certification (date, identification#)

Service Responsibilities (specialty, role, time commitment)

Institutional Administrative Appointments (committees, dates)

Professional Societies (membership, committees, dates, role)

Conference Organizer, Session Chair (sponsor, date, role)

Advisory Committees, Review Groups (sponsor, date, role)

Consultantships (organization/agency, date, role)

Awards, Honors (title, date, description, sponsor)

Invited Talks, Panels (title, date, venue, sponsor)