{"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>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\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_12\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_container'><input name='input_12' id='input_1_12' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_12'>This field is for validation purposes and should be left unchanged.<\/div><\/li><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_2'><span class='gform-field-label__text'>Department\/Division<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_3'><span class='gform-field-label__text'>Primary Site<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_4'><span class='gform-field-label__text'>Faculty Track<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Rank<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_6'><span class='gform-field-label__text'>Email<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label' for='input_1_8'><span class='gform-field-label__text'>Educational Activity<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_9'><span class='gform-field-label__text'>Research Activity<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_1_10'><span class='gform-field-label__text'>Service to UConn Health<\/span><\/label><div class='gfield_description' id='gfield_description_1_10'>List administrative and committee work.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_1_10' class='textarea large'  aria-describedby=\"gfield_description_1_10\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='O1x5FwLjWPb4926AsOlYiRaLJF0ihxjZJopn5p2GqR7hAdsww+QEfLJfnWho3NF\/4TzPBJ2bvZG8Si+rLqSbIGtg4R0x0LIHEAbsYMD7jLsw+E4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n<h2>Explanatory Notes<\/h2>\n<p><strong>Educational Activities:<\/strong> Faculty members are expected to participate in teaching activities during rounds in the office, in the operating room, or in small group conferences at UConn and off-site, including community outreach.<\/p>\n<p><strong>Research Activity:<\/strong> If you are involved in research activities, please list the percent effort in time and the percent of salary covered by grants during the year under review.<\/p>\n<p><strong>Service to UConn Health:<\/strong> List any administrative or committee work for your hospital or the School of Medicine.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Explanatory Notes Educational Activities: Faculty members are expected to participate in teaching activities during rounds in the office, in the operating room, or in small group conferences at UConn and off-site, including community outreach. Research Activity: If you are involved in research activities, please list the percent effort in time and the percent of salary [&hellip;]<\/p>\n","protected":false},"author":38,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-771","page","type-page","status-publish","hentry"],"acf":[],"publishpress_future_action":{"enabled":false,"date":"2026-11-01 01:26:09","action":"change-status","newStatus":"draft","terms":[],"taxonomy":""},"_links":{"self":[{"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/pages\/771","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/users\/38"}],"replies":[{"embeddable":true,"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/comments?post=771"}],"version-history":[{"count":3,"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/pages\/771\/revisions"}],"predecessor-version":[{"id":774,"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/pages\/771\/revisions\/774"}],"wp:attachment":[{"href":"https:\/\/health.uconn.edu\/medicine\/wp-json\/wp\/v2\/media?parent=771"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}