EVMS Academy of Educators Membership Application

Fine Family Academy of Educators Application

Thank you for applying to the Fine Family Academy of Educators. You can save your application and resume it at a later time if you wish. Please note that you must keep the link provided to continue your application after saving, and your application data will only be saved for 30 days. If you would like, you can review the full application in PDF format for reference. This PDF is for reference only, and it includes all the domains regardless of which one(s) you choose. Please complete the online version of the application below to apply. If you have any questions, contact us at thefineacademy@evms.edu.

Full name:*

First Name

Middle Name

Last Name

Email:*

Primary academic department:*

School:*

School of Medicine School of Health Professions

Campus address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Campus telephone:*

Cell/other telephone:

Total years as an EVMS educator as of today's date:*

Academy membership category for which you are applying:*

Member Master Educator

Structured Educator Personal Statement

The following prompts are a guide to help you construct your educator personal statement as an overall description of your educator mission, roles and responsibilities over the last five years. Please complete this section for all membership categories.

Overview of your teaching/educator activities: Overall, what do you do, how much, with whom, when and where?

Overview of your educational leadership and administration/service activities: Provide a general description of relevant formal and informal educational leadership roles and educational administration/service activities. Highlight significant accomplishments and contributions to the school and to the professional education community.

Personal values and core purposes (mission) for teaching and education: What do you believe and value about teaching and learning? How do these theories and values influence the way you teach and pursue education work? What do you strive to achieve as a teacher and educator?

Overview of scholarly engagement in teaching and education: How have you drawn from prior work and the professional field to enhance your educator abilities and/or teaching and learning of others? How have you applied/contributed your educator knowledge and practice to enhance teaching/education?

Your educator goals and future engagement (respond to each of the following): What are your current educator development goals? How do you expect to benefit as an Academy member? How will you contribute to the Academy, as a community of educators?

Direct Teaching

Complete this section and the Teaching Record section below to describe your overall involvement and achievements in teaching in the last five years.

Quantity (Roles and Activities)

Explain here any entries in the Teaching Record necessary for readers to understand and appreciate the significance of your teaching activity. List other evidence and/or reference entries already in your CV.

Quality (Effectiveness and Excellence)

Consider including the following: Summary table or graph of student ratings of teaching (include comparative results, as available) as an appendix item and reference page(s) in the field below; Description of narrative feedback from students with several representative quotes; Examples of teaching improvement strategies that resulted in significant gains in student learning (e.g., as measured by learner assessments); Other documentation/evidence of quality (repeated invitations as guest teacher/presenter; specific learner outcomes). For items already listed in the CV, reference page and citation here.

Engagement (Collaboration, Scholarly Approach, Scholarship, Contributions/Impact)

Consider listing the following: Activities and descriptions of ways in which you have engaged with others about teaching practices (including participation in faculty development workshops, presentations at meetings, involvement and contributions on teaching/education/curriculum committees and work groups); Actions/activities for innovation and improvement in teaching and connections to prior work, literature, and best practices; Specific contributions and outcomes (significant results) relative to innovative teaching methods; Reference items in your CV for presentations, publications, and other scholarly activities pertaining specifically to teaching (peer reviewer, invited presenter or consultant, grant-funded initiatives pertaining to teaching).

Teaching Record

Please list your teaching activities over the past five years.

How many teaching activities would you like to list?

Activity 1

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 2

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 3

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 4

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 5

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 6

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 7

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 8

Academic year (e.g. 2018-19):

Name of activity

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 9

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Activity 10

Academic year (e.g. 2018-19):

Name of activity:

Number of learners:

Estimated number of learners enrolled/participating in the course/educational program.

Hours:

Estimated number of hours involved in direct teaching with learners.

Educational Leadership and Administration

Complete this section along with the Educational Leadership and Administration Record section to describe your overall involvement and achievements in educational leadership and administration in the last five years.

Quantity (Roles and Activities)

Highlight specific entries in the educational leadership record above and provide any additional explanation necessary for readers to understand and appreciate the level of involvement and commitment that occurred.

Quality (Effectiveness and Excellence)

List other examples of evidence here or reference CV entries. Examples include: summary of leadership assessments; completion of a leadership development or certificate program; frequency of appointments to leadership roles and elected positions; awards and recognition/commendation letters; specific outcomes or achievements that resulted directly from your leadership activities and initiatives.

Engagement (Collaboration, Scholarly Approach, Scholarship, Contributions/Impact)

List activities (or reference relevant CV entries) and describe ways in which you have engaged with others regarding areas in this domain. For example: Faculty development workshops; presentations at meetings focused on solving a problem/issue or seizing an opportunity); Actions/activities for innovation and improvement in this domain and connections to prior work, literature and best practices; List of specific contributions and outcomes (significant results) resulting from actions targeting innovation and excellence in this domain; List or reference items in your CV for presentations, publications, and other scholarly activities pertaining specifically to this domain.

Educational Leadership and Administration Record

Please list your roles in educational leadership and administration.

How many roles would you like to list?

Role 1

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 2

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 3

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 4

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 5

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 6

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 7

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 8

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 9

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Role 10

Academic year:

Title:

Clinical or medical director, course/ clerkship director, department/ division chair, dean, etc.

Unit location:

Scope:

Department/Program EVMS-wide External to EVMS

Role

Volunteer Elected Appointed

Educational Leadership and Administration Record (continued)

This section is required if applying for the category of Master Educator, but optional if applying for the category of member. Complete this section to provide details of one of your best/most significant achievements in educational leadership or administration within the last five years.

Title or description of project/initative:

Inclusive dates:

Describe the need, problem, or opportunity:

Rationale for change or innovation:

Goal(s):

Your leadership role(s):

Your specific contribution(s) and impact:

Target audience:

Primary collaborators:

Action taken and connection to prior work, literature and best practices:

Resources obtained and how used to achieve goal(s), desired outcome(s) (e.g., people, technology, internal budget, grants, funding awards):

Outcomes/Impact:

Dissemination:

Advising and Mentoring

Complete this section along with the Advising and Mentoring Activity Record section to describe your role in advising and mentoring in the last five years.

Quantity (Roles and Activities)

Provide an overall description of advising and mentoring over the last five years. Include any other supporting evidence in the last five years (e.g., descriptions or reference to specific CV entries) that is not already in the Advising and Mentoring Record below.

Quality (Effectiveness and Excellence)

Include significant evidence of quality (e.g., achievements, consistent record of positive outcomes across advisees/mentees). Examples of evidence may include: Frequency of peer referrals; awards for excellence in advising or mentoring; letters or other communications that provide evidence of quality; peer recognition (e.g., invitations to present or consult with colleagues; list of specific contributions and outcomes (significant results) resulting from actions targeting innovation and excellence in advising and mentoring.

Engagement (Collaboration, Scholarly Approach, Scholarship, Contributions/Impact)

List activities or reference relevant CV entries and describe ways in which you have engaged with others regarding areas in this domain. Examples may include: Faculty development workshops; program development; actions or activities for innovation and improvement in this domain and connections to prior work, literature and best practices; presentations, publications, and other scholarly activities from your CV that pertain specifically to this domain.

Advising and Mentoring Record

List a record of your mentoring over the past five years.

How many mentoring activities would you like to list?

Mentoring Activity 1

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 2

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 3

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 4

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 5

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 6

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 7

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 8

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 9

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Mentoring Activity 10

Years:

Enter the beginning and ending year for the relationship.

Name of mentee:

In some situations, it may not be appropriate or in the best interest of the advisee/protégé to insert his/her name. In such cases, prove a brief description (e.g., first-year medical student, PGY-2, junior faculty, etc.

Level of training:

Purpose/goals:

Outcomes:

List the primary results/impact of the relationship (e.g., goal attainment, problem resolved, award, presentation/paper acceptance, publication, career advice.

Educational Research and Scholarship

Quantity (Roles and Activities): Include a brief overview of the focus and scope of your work in educational research, and/or scholarship, giving emphasis to what you’ve done within the last five years.

If applicable, describe specific formal roles and responsibilities you have at EVMS and elsewhere that relate to educational research and scholarship. Describe current, in-progress projects and activities and why they are important. Examples: Reference specific entries from your CV that represent educational research (creating, implementing, assessing the impact/outcomes of an educational intervention) and scholarship (dissemination of new products that advances thinking, knowledge and practice in the field); include entries regarding any specific roles and responsibilities (e.g., teaching others how to do educational research). These may be within and/or outside EVMS (e.g., professional organization) Remember to also include/reference evidence of non- published/disseminated work completed for internal purposes only.

Quality (Effectiveness and Excellence): Provide an overview description of how you define and seek to achieve quality in educational research and/or scholarship.

Consider these questions: What have you done to enhance the quality of your knowledge and skills? What have you done to maximize effectiveness and excellence in what you do within this domain? How do you know when effectiveness and excellence have been achieved? What have you completed to advance your abilities in this domain (e.g., formal education, faculty development, engage with a coach/mentor, conferences and skills development)? Consider providing a summary of peer review critique and feedback, describing success in competitive processes for internal and external project funding or highlighting specific contributions of your work both for internal projects shared within EVMS and/or disseminated, peer-reviewed beyond EVMS.

Engagement (Collaboration, Scholarly Approach, Scholarship): Provide an overview description of how you collaborate with others in the processes of engaging in educational evaluation, research, and scholarship.

Consider these questions: How do these activities contribute to your engagement with various groups within and outside of the EVMS educator community? What are you considering for future goals and activities to expand or enhance your engagement with others? Why? Consider providing examples of networking and outreach strategies and results in achieving engagement and/or collaboration with others or examples of how literature review and best practices have been used to ground specific projects. Consider referencing projects in your CV or list collaborative projects that have been completed, include any ongoing collaborative relationships or providing specific line(s) of inquiry or focus that you have pursued in your activities and brief examples of their results and impact.

Educational Research and Scholarship: Educator Portfolio

Complete this section to provide details of one of your best/representative examples of your engagement in educational research or scholarship. This section is optional if you are applying for the category of Member but is required if applying for Master Educator.

Title or description of study/project:

Purpose (clear goals):

Relevant literature, prior work, and best practices (adequate preparation):

Context (problem, issue, opportunity):

Audience:

Your role:

Primary collaborators:

Research design (appropriate methods):

Results, outcomes, impact (significant results):

Dissemination/publication (effective presentation):

Review, critical appraisal and/or resulting follow-up inquiry or activity (reflective critique):

Impact or value added to the institution:

Curriculum Development and Assessment of Learning

Describe your overall engagement and achievements in either curriculum development or assessment for the last five years.

I would like to describe my engagement/achievements in:

Curriculum development Assessment of learning

Curriculum Development Record

Quality (Effectiveness and Excellence):

Consider providing results of peer review completed by committees or colleagues at other institutions, course or program reviews (internal and/or external) or examples of how you helped to improve student and faculty perceptions or improved learning outcomes (e.g., test scores).

Engagement (Collaboration, Scholarly Approach, Scholarship, Contributions/Impact):

Consider listing or referring to information already included in your portfolio or CV and describing ways in which you have engaged with others (including faculty development workshops, presentations at meeting) or providing evidence of relevant literature and/or best practices used to ground work. You may also consider including: Requests from others to adopt/adapt materials; a list of specific contributions and outcomes resulting from actions targeting innovation and excellence in this domain; a list or reference to CV entries for presentations, publications, dissemination, etc.

How many curriculum development activities would you like to list?

Curriculum Development Activity 1

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 2

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 3

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 4

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 5

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 6

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 7

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 8

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 9

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development Activity 10

Academic year (e.g., 2017-18):

Curriculum name/topic:

Number of learners:

Learner level:

Undergraduate students Graduate/PhD students Residents Fellows Faculty development Continuing education

Number of hours:

Curriculum/course length (e.g., entire program or year, a course, series of seminars or labs, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment of Learning

Quality (Effectiveness and Excellence):

Consider including the following: Results of peer review completed by committees or colleagues at other institutions; evidence of improved student and faculty perceptions resulting from your developments; evidence of improved learning outcomes (e.g., test scores); course or program reviews (internal and/or external).

Engagement (Collaboration, Scholarly Approach, Scholarship, Contributions/Impact):

Consider including the following: A list of activities (or references to information already included in the portfolio or CV) and descriptions of ways in which you have engaged with others regarding areas in this domain (including faculty development workshops, presentations at meetings); evidence of relevant literature and/or best practices used to groundwork; requests from others to adopt/adapt materials; a list of specific contributions and outcomes (significant results) resulting from actions targeting innovation and excellence in this domain; a list of or references to CV entries for presentations, publications dissemination, etc.

How many assessment activities would you like to list?

Assessment Activity 1

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 2

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 3

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 4

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 5

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 6

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 7

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 8

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 9

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Assessment Activity 10

Academic year (e.g., 2017-18):

Number of hours:

Number of learners:

Context of assessment (name of course, clerkship, continuing education program, etc.):

Your role and degree of responsibility (leader and instructor, adviser/consultant, etc.):

Curriculum Development and Assessment of Learning (continued)

This section is optional when applying for the Member category, but is required when applying for the Master Educator category. Complete this section to provide further details about one of your activities as relates to curriculum development or assessment (whichever you chose above).

Title or description of activity:

Category:

Curriculum development Assessment of learning

Primary focus:

Original/new Revision Major Minor Ongoing refinement

Your role and contribution(s):

Collaborators and consultants:

Describe the context in which this work occurred (e.g., specific need, problem, opportunity, or target of change or innovation):

Demonstrate how you met scholarship attributes and provided value to the institution using the six attributes listed below:

Clear goals:

Adequate preparation:

Appropriate methods:

Significant results (outcomes):

Effective presentation:

Reflective critique (next steps for continued improvement):

Dissemination:

Revenue (including grants):

Updated CV

Please attach your updated CV in the field below.

Updated CV*

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Supplementary Documents

Item 1

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Item 2

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Item 3

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Item 4

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Attestation

Applicant attestation:*

I have personally assembled this application as an accurate representation of my educator engagement, achievements, and contributions in teaching and education. If accepted, I agree to fulfill the member expectations that are necessary to maintain active member in good standing status and understand that failure to do so will terminate my Academy membership.

Digital signature of applicant:*

First Name

Last Name

Date:*

Supervisor's name:

First Name

Last Name

Supervisor's email:

Please note: Enter your email on the Save and Resume page to have the link sent to you for future use. If you opt to save your application data and complete the application at a later time, you MUST keep the link provided to continue your application after saving. Without the link, the data you have entered cannot be retrieved, and you will have to start filling out the form at the beginning. Your application data will only be saved for 30 days.