Office Address: (Required) Telephone: (Required) Office Fax Number: (Optional) Institutional E-mail Address (Required) REQUIRED CV COMPONENTS for NAME Date of Preparation: (Required) Signature (Required) *Electronic signatures are not acceptable For each category on the CV: List items in reverse chronological order Number all lists (ex: publications, presentations) Copy and paste the initial row in each section to add an item Indicate dates in entries when applicable, utilizing the column on the right side of the entry Eliminate any heading for which there is no entry. Add headings as appropriate to your work EDUCATION List name of institution, location, date, type of degree for each Graduate: Baccalaureate: Other: POSTGRADUATE TRAINING List fellowships, residencies, internships, etc. FACULTY APPOINTMENTS List current and prior faculty appointments to WSU or other Universities HOSPITAL OR OTHER PROFESSIONAL APPOINTMENTS For Voluntary Faculty Appointments, identification of the primary affiliation and all other affiliations are Required MAJOR PROFESSIONAL SOCIETIES MEDICAL LICENSURE All States (Note if active or inactive) List Michigan license number and inclusive dates (if applicable) BOARD CERTIFICATION Include certification number and date of expiration 1
REQUIRED CV COMPONENTS for HONORS/AWARDS SERVICE Indicate the activity and your role. DO NOT list if you are a member, but have provided no additional service. Wayne State University Required if any Departmental/Divisional School of Medicine University Other UPG or other physician practice plan Affiliate medical organizations (e.g., DMC, KCI, VA, HFH, Oakwood, etc.) Required if any Professional (e.g., medical or scientific organizations and societies) Community (e.g., presentations for lay audiences, educational outreach, media presentations/interviews) Consulting Scholarly Service Grant Review Committees Indicate whether full member, ad hoc, or telephone reviewer. National/International Regional/Local Service for Peer-Reviewed Journals Editorship Editorial Board Membership Review of Manuscripts Other Scholarly Service (e.g., Institutional Review Board, Clinical Evaluation Committee, Data and Safety Monitoring Board, moderator for scientific session) OTHER SERVICE 2
TEACHING REQUIRED CV COMPONENTS for For Voluntary Faculty Appointments at the rank of Clinical Associate or Clinical Full Professor: A description of the candidate s teaching (for WSU and other institutions) is required Wayne State University Teaching at Wayne State University List the course number, title, and/or type of teaching activity, and your role under each of the categories below: Indicate year(s) when taught. Undergraduate Students Graduate Students Medical Students Residents/Fellows Faculty (CME) Years at other Colleges/Universities (please list institutions) Teaching at other Institutions Under the categories below, list course title, and/or type of teaching activity, and your role under each of the categories below: Indicate year(s) when taught. Undergraduate Students Graduate Students Medical Students Residents/Fellows Faculty (CME) Mentorship Define and list the names of mentees (e.g. student, resident, fellow, and faculty) Essays/Theses/Dissertations directed Define and list the names of mentees (e.g. student, resident, fellow, and faculty) Course or Curriculum Development Include electronic instruction (e.g. online instruction, course development, and webinars). Be sure to include visiting Professor or Lecturer Positions (e.g. invited short courses, or lectures, plus interactions with students/trainees). 3
REQUIRED CV COMPONENTS for OFAPD_REQCV_VFA_090414 GRANTS, CONTRACTS, AND OTHER FUNDING Indicate role (PI, Co-PI, Co-I, etc.), percent effort, title, source, total period of support, total direct costs. Active National/International Grants and Contracts Example Role: Co-Investigator., Percent Effort: 10% Title: Infrastructure Development Program Source: HRSA/AHEC Total Direct Costs: $2,680,172 09/01/12-08/31/17 Active Other Grants and Contracts Pending National/International Grants and Contracts Pending Other Grants and Contracts Previously funded Grants and Contracts Previously submitted, not funded Grants and Contracts CLINICAL TRIALS ACTIVITIES Include trials in which you have a major role; define your contribution, e.g., PI or co-pi, site PI for multi-center trial, protocol committee member. PATENTS Status, date, number, title, and role (e.g., indicate if primary inventor or coinventor.) PUBLICATIONS List, in reverse chronological order, publications that are published or accepted and in press, but not those merely submitted or in preparation. Annotations are not required for first, senior, or corresponding authorship. o o For all others, describe your role in each publication. Possible roles include: study conception, design, implementation (including patient recruitment), data analysis, manuscript writing. Indicate with an asterisk any co-author who is a student or trainee (if applicable), and provide a legend at the foot of the page. Peer-Reviewed Publications Include all formats, including articles in electronic-only journals. Reports of Original Work 4
REQUIRED CV COMPONENTS for OFAPD_REQCV_VFA_090414 Case Reports Examples: Mastrobattista JM, Parisi VM. Vertical transmission of a Citrobacter infection. American Journal of Perinatol. 1997 Sep; 14(8):465-7. Monga M, Benson GS, Parisi VM. Renal cell carcinoma presenting as hemolytic anemia in pregnancy. American Journal of Perinatol. 1995 Mar; 12(2):84-6. Review Articles Examples: Thorp JA, Dildy GA, Yeomans ER, Meyer BA, Parisi VM. Umbilical cord blood gas analysis at delivery. American Journal of Obstetrics and Gynecology. 1996 Sep; 175 (3 Pt 1):517-22. Review. Nielsen PE, Abouleish E, Meyer BA, Parisi VM. Effect of epidural analgesia on fundal dominance during spontaneous active-phase nulliparous labor. Anesthesiology. 1996 Mar; 84(3):540-4; discussion 29A. Editorials/Commentaries Letters to the Editor Book Authorships, Editorships, and Chapters Example: Lam, G and Parisi, VM: Chapter 27: Preeclampsia and Eclampsia in Pregnancy. In Runge, MS and Greganti, MA: Netter's Internal Medicine, Icon Learning Systems, 2003. Published Abstracts (must have a reference that can be looked up) Non-peer-reviewed publications Other (please specify) PRESENTATIONS Podium Presentations (refereed) Poster Presentations (refereed) Other (example: videos) Invited Lectures/Presentations International/national Local/regional Invited Seminars and Grand Rounds 5