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Document 2224302
Double click here to open, then highlight text to replace with first name, last name, suffix
1
Academy Member Annual Report
Cover Page
Name:
Position/Title:
School:
Double-click to select
Primary Department:
Campus Address/Office Location:
Campus Telephone:
Campus Email:
As of today’s date, number of years employed as a LSUHSC faculty member:
Your current faculty rank:
Instructor
Is this a tenure-track appointment?
Yes
No
Achieved tenure already?
Yes
No
Year Inducted:
_______
Current Academy membership
category:
Assistant Professor
Associate Professor
Professor
Not applicable
Associate
Fellow
Master Teacher
Teaching Scholar
Check the teaching/education domains for which you have included information in this membership renewal application:
Teaching
Curriculum Development,
Instructional Design &
Assessment of Student
Learning
Advising and
Mentoring
Leadership and
Service
Educational
Research
I attest that the content of this membership renewal application is accurate and the result of my own work.
____________________________________________
Academy Member Signature
_____________________________________
Date Submitted
Composition of the Academy Membership Renewal Application
Your Academy membership renewal application includes the following components:
1.
2.
This cover page
Narrative report
Narrative Report: Quantity, Quality, and Engagement in Teaching and Education
General Directions: Complete the table below and report only teaching and education activities and achievements since your
induction into the Academy. Some prompts are included in the cells and footnotes to help you decide what information to include.
Simply replace the highlighted text in each cell with your own information. Be sure to include relevant descriptions and forms of
evidence for each educational domain that you checked on the cover page. Entries may be narrative or bullet format. Be concise, but
complete enough for reviewers to understand your involvement and achievements and can provide effective, specific feedback. When
events, presentations, publications in teaching/education are reported, please be sure to provide the complete reference/citation in the
Evidence section for Engagement. If such evidence is already included in your CV, then reference the specific CV entries and include
the page and item number(s where they are located).
Quantity
(Roles and Activities)
Narrative/Description
Brief description of scope and examples of roles and
activities
Evidence
Complete and reference the Teaching Record (next
page); List other entries that provide evidence of
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Quality
(Effectiveness and
Excellence)
Engagement
(e.g., Collaboration;
Academy participation1,
Scholarly Approach2,
Scholarship3,
Contributions/Impact)
Describe the specific aspects of effectiveness and/or
excellence you have achieved/sought to achieve
(e.g., increased student ratings of teaching, learning
outcomes that result from a new curriculum)
Provide an overview description of how you have
collaborated and participate with others in teaching
and education and engaged in the community of
educators (please see footnotes)
2
quantity
List here the specific results or outcomes/products
that provide evidence of the quality features you
described to the left.
List collaborative projects, Academy events, faculty
development
workshops,
publication
and
presentation citations from your CV or you can
attach your CV and reference exactly where in your
CV the evidence is located (e.g., page #, citation #).
Required Appendix Items
1.
Curriculum Vitae – This document can be in any format (e.g., the formation required for your School).
2.
Annual Academy Activity Reports – Please include a copy of each annual Academy activity report since your induction into the
Academy. At the end of each academic year, these reports have been sent to you as a summary of the specific Academysponsored activities in which you have participated. . If you did not keep these reports, please contact Ms. Kelly Nester at
504-568-2140 or send an email message to [email protected] to request a duplicate copy.
3.
Academy leadership and service contributions – Please provide a list of your leadership roles and service contributions to the
Academy since your induction (e.g., membership on a team, peer review panel, Advisory Group, Executive Council) and
provide a brief description of your specific contributions for each.
Academy participation – describe/list Academy workshops, symposia, meetings, projects, teams, etc. in which you participated in the past 12
months.
2 Scholarly approach – includes activities such as drawing from the literature, adopting best practices, building on the work of others to innovate,
improve, and/or expand your teaching and education work.
3 Scholarship in teaching and education can include how you have contributed to the educational community (e.g., disseminated the outcomes or
products of your scholarly work in teaching and education). Among these activities may be presentation/publication citations, a bulleted list of
dissemination activities by date and brief description, list of individuals or other organizations who have benefited from your scholarly work (e.g., peer
review and critique, adoption or adaptation of an educational method or enduring material that you have created and disseminated).
1
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3
TEACHING RECORD of Activities
Name:
School:
Date:
Page:
of
Please complete for only the most recently completed academic year (i.e., July 2009 – June 2010). Add rows to the table, as
needed.
Year4
Course Title
Course5
R
E
Hours6
Number of
Learners7
Learner Level8
Teaching Method(s)9
1 2 3 4 5 6 7 8 9 10 11 12
4Please indicate the academic year in which each teaching activity occurred (e.g., 2007-2008, 2008-2009). Include at least the most recent two
years and no more than the most recent five years at LSUHSC-NO.
5R=Required/Core Curriculum Course; E=Elective Course
6Number of hours involved in direct teaching with learners
7Number of learners enrolled/participating in the course/educational program
8Write in each cell the code(s) that apply for the course (Modify key to reflect appropriate learner groups):
Y1, Y2, Y3, Y4, G = Ph.D./Graduate, PGY1, PGY2, PGY3, F = Fellow, FD = Faculty Development, C =
Continuing Education
9Circle all numerical codes that apply using the following key (Modify the key to reflect relevant teaching
methods for your particular situation):
1= Lecture; 2 = Lecture/Demonstration; 3 = Laboratory; 4 = Small Group/Case-Based;
5 = Small Group/Discussion; 6 = Small Group/Seminar; 7 = Hospital/Inpatient/Bedside Rounds;
8 = Hospital/Clinic; 9 = Community/Clinic; 10 = One-to-one, Laboratory/Research Preceptor
11 = One-to-one, Clinical Preceptor; 12 = Distance Learning
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