Maintenance of Appointment (Moa)

MAINTENANCE OF APPOINTMENT (MOA)

Faculty Member

Candidate for MOADepartment

RankTrackDate appointment terminates without maintenance

To be completed by the faculty member and submitted to the Department Chair, along with items 1-4:

___ 1.Updated curriculum vitae in the VTCSOM format.

Please note: clinicians (MD, DO, MBBS, etc.) currently practicing medicine should include the following information on the updated CV: state of medical license, license number, expiration date; board certifications, including date of initial certification, date of most recent board certification and date at which next certification is due.

• Board certification 1: Is recertification required to maintain current status?YesNo
• Board certification 2: Is recertification required to maintain current status?YesNo
• Board certification 3: Is recertification required to maintain current status? YesNo

___2.Completed Faculty Information Form (attached)

Completion of the Faculty Information Form provides VTCSOM with up-to-date contact information. The section for self-identification assists us in demonstrating our efforts in recruiting a diverse faculty. Your assistance in providing this information assures VTCSOM remains compliant with our accrediting agencies.

___3.Completed Faculty Involvement Form(attached)

A faculty appointment requires participation in the fulfillment of the mission of VTCSOM through teaching, assessment/evaluation, curriculum development, administrative duties or other types of service. MOA certification may involve resident/fellow oversight or teaching activity assuming those residents/fellows interact with VTCSOM students.

___4.Signed FERPA (Family Educational Rights and Privacy Act of 1974) Confidentiality Agreement for Faculty (attached)

The Family Educational Rights and Privacy Act (FERPA) of 1974 is a Federal law that protects the privacy of student education records. The law applies to all schools receiving funds under an applicable program of the U.S. Department of Medicine.

___5.Please indicate you receive and review annual notifications of Faculty Handbook revisions Yes No

The policies and procedures are presented to all faculty at the time of the required faculty orientation. In addition, all faculty are reminded to review the faculty handbook prior to the yearly meeting of the Faculty Assembly (revisions to the handbook are distributed to faculty for review prior to voting). The faculty handbook is available on the VTCSOM website.

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Signature of faculty memberName printedDate

To be completed by Chair of Departmental APRT Committee:

MOA recommended by Departmental Committee______

(please ensure all attachments are included)Name printed - Chair of Departmental APRT CommitteeDate

______

Signature - Chair of Departmental APRT Committee

Termination of appointment recommended______

Signature – Chair Departmental APRT CommitteeDate

To be completed by Department Chair prior to submission to Dean’s office:

Duration of next appointment after review(up to 3 years)______

MOA endorsed (please ensure attachments are included)______

Signature – Department ChairDate

Termination of appointmentendorsed______

Signature – Department ChairDate

Checklist for Maintenance of AppointmentApril 23, 2015