{"id":771,"date":"2016-10-20T16:19:21","date_gmt":"2016-10-20T20:19:21","guid":{"rendered":"https:\/\/health.uconn.edu\/medicine\/?page_id=771"},"modified":"2016-10-20T16:21:24","modified_gmt":"2016-10-20T20:21:24","slug":"academic-activity-report-form","status":"publish","type":"page","link":"https:\/\/health.uconn.edu\/medicine\/academic-activity-report-form\/","title":{"rendered":"Academic Activity Report Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' ><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/medicine\/wp-json\/wp\/v2\/pages\/771' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_1\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><label class='gfield_label gform-field-label' for='input_1_2'>Department\/Division<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><label class='gfield_label gform-field-label' for='input_1_3'>Primary Site<\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_1_3' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose one:<\/option><option value='Connecticut Children&#039;s Medical Center' >Connecticut Children&#039;s Medical Center<\/option><option value='Hartford Hospital' >Hartford Hospital<\/option><option value='Northeast Pediatric Specialist' >Northeast Pediatric Specialist<\/option><option value='Private Practice' >Private Practice<\/option><option value='Saint Francis Hospital and Medical Center' >Saint Francis Hospital and Medical Center<\/option><option value='The Hospital of Central Connecticut' >The Hospital of Central Connecticut<\/option><option value='The Jackson Laboratory' >The Jackson Laboratory<\/option><option value='UConn Health' >UConn Health<\/option><option value='VA Medical Center' >VA Medical Center<\/option><\/select><\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>Faculty Track<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_1_4' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose one:<\/option><option value='Affiliated Faculty' >Affiliated Faculty<\/option><option value='Community-based Faculty' >Community-based Faculty<\/option><option value='Adjunct Faculty' >Adjunct Faculty<\/option><\/select><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Rank<\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_1_5' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose one:<\/option><option value='Assistant Professor (Affiliated Faculty)' >Assistant Professor (Affiliated Faculty)<\/option><option value='Associate Professor (Affiliated Faculty)' >Associate Professor (Affiliated Faculty)<\/option><option value='Instructor (Affiliated Faculty)' >Instructor (Affiliated Faculty)<\/option><option value='Professor (Affiliated Faculty)' >Professor (Affiliated Faculty)<\/option><option value='Clinical Associate' >Clinical Associate<\/option><option value='Clinical Instructor' >Clinical Instructor<\/option><option value='Assistant Clinical Professor' >Assistant Clinical Professor<\/option><option value='Associate Clinical Professor' >Associate Clinical Professor<\/option><option value='Clinical Professor' >Clinical Professor<\/option><option value='Adjunct Professor' >Adjunct Professor<\/option><option value='Adjunct Associate' >Adjunct Associate<\/option><option value='Adjunct Instructor' >Adjunct Instructor<\/option><option value='Adjunct Assistant Professor' >Adjunct Assistant Professor<\/option><option value='Adjunct Associate Professor' >Adjunct Associate Professor<\/option><option value='Adjunct Professor' >Adjunct Professor<\/option><\/select><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-email field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>Email<\/label><div class='gfield_description' id='gfield_description_1_6'>Institution email if affiliated faculty appointment.<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_1_6' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_1_6\" \/>\n                        <\/div><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><h2 class=\"gsection_title\">Eligibility for Continued Faculty Appointment<\/h2><div class='gsection_description' id='gfield_description_1_11'>Affiliated, community-based and adjunct faculty, please describe your current contributions to the academic programs and\/or research mission of the School of Medicine from January 1, 2016 to December 31, 2016<\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Educational Activity<\/label><div class='gfield_description' id='gfield_description_1_8'>List Undergraduate (UME) and Graduate Medical Education (GME) Activities.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_1_8' class='textarea large'  aria-describedby=\"gfield_description_1_8\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>Research Activity<\/label><div class='gfield_description' id='gfield_description_1_9'>List the grants you collaborate on.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_1_9' class='textarea large'  aria-describedby=\"gfield_description_1_9\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Service to UConn Health<\/label><div class='gfield_description' id='gfield_description_1_10'>List administrative and committee work.<\/div><div 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