HEALTH SYSTEM CLINICIAN COVER SHEET: NEW APPOINTMENT (proposed by NM CMO)

Candidates complete section 1 of this form and provide it to your CMO, who will complete the remainder and submit it to the appropriate FSM Department Chair’s Office to propose a physician for appointment to the FSM faculty as a Health System Clinician.

1. CANDIDATE INFORMATION – Completed by the candidate
Last Name / First Name / Middle Initial / Degree(s)
Preferred Email Address / NPI Number
Employer (HSCs are not employed by FSM or Northwestern University. Please confirm the physician’s employer below.)
NM Regional Medical Group (NMRMG) / Private Practice (specify):
Northwestern Medical Group (NMG) / Other (specify):
Current/Pending Hospital Privileges (Check all that apply; please prioritize by ranking as 1, 2, etc. if more than one hospital)
____ NMH
____ LFH / ____ CDH
____ Delnor / ____ Kishwaukee
____ Marianjoy / ____ Valley West
____ RIC / ____ Lurie Children’s
____ Jesse Brown VA / ____ Stroger
____ Other (specify): / ____ No privileges
2. CMO’S REVIEW AND RECOMMENDATION
Appointment Requested / Proposed FSM Department / Division / Proposed FSM Start Date / Tenure Status
Health System Clinician (HSC) / Non-tenure-eligible
CMO’s Decision: / Appointment Recommended (explain below) / Appointment Not Recommended (explain below)
Reason for Decision: Provide a brief description of the candidate and an explanation for the CMO’s decision.
CMO’s Signature / Date
CMO’s Name (typed or printed) / Hospital Name
3. CMO’S SUBMISSION TO FSM DEPARTMENT
The Office of the CMO submits the following documents to the appropriate FSM Department Chair’s Office.
This form, completed through section 3
Candidate’s CV
Candidate’s Personal Data Form
4. FSM DEPARTMENT USE ONLY: DEPARTMENT CHAIR’S REVIEW
Department Chair’s Decision: Approved as HSC Approved as HSC/NMH Appointment Not Approved
Note: If the Department Chair reverses the recommendation of the CMO, please communicate that to the Office of the CMO.
Division Chief’s Signature (if applicable) / Date / Department Chair’s Signature / Date
5. FSM DEPARTMENT USE ONLY: SUBMISSION TO FAO (only if Department Chair Approves Appointment)
Documents received from CMO in step 3 (with this form approved by FSM Department Chair)
Position Data and Appointment Forms (HSC job code=102073; position type=FAC; position category=HSC; annual
renewable=Y; indefinite end to appointment=Y; do NOT enter an appointment end date)

Version Date: 11/17/2016