Spreadsheet: 20f88301-c251-4efd-8470-730293d2a386
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9
Last Name, First Name, Middle Initial |  |  | Department |  | Division/Section
Academic Rank |  |  | Series I, II, or III
At above rank at Morehouse School of Medicine since:
 |  |  | Month |  | Year
Consider your activities for this review period only:  July 1, 2010 through June 30 2011.   Make your estimates
on the basis of total effort, irrespective of where or when the activity was carried out.
When you have completed the FAR, schedule an appointment to review it with your chair.
After the discussion, each of you should complete the appropriate section below:
Your Department Chair will submit the form and an evaluation of you to the [NAME].
To be completed by the Department Chair:
I have discussed this report with ____________________________________ on ______________ |  |  |  |  |  | date
______  I concur with the data entered in the Faculty Activity Report.
____________________________________________
Signed, by the Faculty Member
_________________________________________
Signed, by the Division/Section Chief
_________________________________________ |  |  | ______________________________________
Signed, by Center/Institute Director |  |  | Signed, by the Chair
A. | TEACHING ENCOUNTERS |  |  |  | % Effort _______
1. | CLASSROOM.   Indicate the NUMBER of hours by category in the applicable column at right.
 | For Morning Report, simply write in the total number of hours attended during this review period.
 | Undergraduate |  |  | Graduate
 | (M.D.) |  |  | (Residents/PhD)
 | M1/M2 | M3/M4 | CPC/ |  | Morning
 | Lecture | Lecture | M&M | Lecture | Report
2. | CLINICAL.  [To arrive at the TOTAL NUMBER per year, multiply the columns identified in brackets next to
 | the activity.]
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Clinical Teaching Activity |  | # of | # of | # of | # of | Total
 | (Time spent with either residents or students) |  | Sessions | Weeks | Days | Months | Number
 |  | Location | Per Wk | Per Mo | Per Yr | Per Yr | Per Year
 | Month long Ward Attending [d]
 | Month long Consult Attending [d]
 | (>15 consults per/wk)
 | Month long Critical Care [d]
 | 1/2 day clinic w/residents/students [a x b x d]
 | On Call at Home -- one day [c]
 | On Call in Hospital -- one day [c]
 | Operating Room - one day [c]
3. | OTHER.  [List other teaching activities during this review period that are not included above].
 | Teaching Activity |  |  | Location |  |  | # Done
4.
B. | ADMINISTRATION/PROFESSIONAL SERVICE |  |  |  | % Effort _______
1. | COMMITTEE ASSIGNMENTS AT MSM AND AFFILIATED HOSPITALS  [List all committee assignments during this
 | review period, including ad hoc committees.  [NAME] the information in the columns at the right.]
 |  |  |  | Responsibility |  | Meeting | [NAME]
 | Committee Name (Institutional) | Location/Site |  | Chair | Member | Frequency | per Mtg
 | Committee name (Departmental)
 | Committee name (Other)
 | ADMINISTRATIVE POSITIONS AT MSM AND AFFILIATED HOSPITALS.   [List administrative positions held during
 | this review period, e.g., course director, residency program director, division/section chief, clinic/medical director.]
 | Description |  |  |  | Location/Site
2.
 | SERVICE ACTIVITIES OUTSIDE MSM  [Describe all PROFESSIONAL service activities performed outside MSM
 | during this review period, e.g., grants reviewer, consultation to outside agencies, chair or member of national
 | or local committees.]
 | Activity | Agency |  |  | Date(s)
3.
 | RESEARCH |  |  |  | % Effort _______
 | GRANTS & CONTRACTS  (G&C).    [Include all research grants and contracts that have been developed and
 | submitted during this review period.  [NAME] all sections that apply.  Use one block for each grant or contract.]
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Grant  [      ]               Contract  [       ] |  | Submitted/ |  | New or | Current | Salary
C. |  |  | Not Funded/ | Continu- | Competing | Year | Covered
 | Title: __________________________________________ |  | Pending | ation | Renewal | Budget | by G&C
1.
 |  |  |  |  |  |  | % Effort
 | Role:  [    ] PI      [     ]  Co-PI     [     ]  Investigator
 | Funding Agency:      [     ]  National     [     ]  Local |  |  |  |  |  | $ [NAME]
 | Entire period of [NAME]:
 | Total Award:  $ ___________________
 | Indirect Cost Rate:   _________%
 | GRANTS AND CONTRACTS (continued)
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Grant  [      ]               Contract  [       ] |  | Submitted/ |  | New or | Current | Salary
 |  |  | Not Funded/ | Continu- | Competing | Year | Covered
 | Title: __________________________________________ |  | Pending | ation | Renewal | Budget | by G&C
 |  |  |  |  |  |  | % Effort
1.
 | Role:  [    ] PI      [     ]  Co-PI     [     ]  Investigator
 | Funding Agency:      [     ]  National     [     ]  Local |  |  |  |  |  | $ [NAME]
 | Entire period of [NAME]:
 | Total Award:  $ ___________________
 | Indirect Cost Rate:   _________%
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Grant  [      ]               Contract  [       ] |  | Submitted/ |  | New or | Current | Salary
 |  |  | Not Funded/ | Continu- | Competing | Year | Covered
 | Title: __________________________________________ |  | Pending | ation | Renewal | Budget | by G&C
 |  |  |  |  |  |  | % Effort
 | Role:  [    ] PI      [     ]  Co-PI     [     ]  Investigator
 | Funding Agency:      [     ]  National     [     ]  Local |  |  |  |  |  | $ [NAME]
 | Entire period of [NAME]:
 | Total Award:  $ ___________________
 | Indirect Cost Rate:   _________%
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Grant  [      ]               Contract  [       ] |  | Submitted/ |  | New or | Current | Salary
 |  |  | Not Funded/ | Continu- | Competing | Year | Covered
 | Title: __________________________________________ |  | Pending | ation | Renewal | Budget | by G&C
 |  |  |  |  |  |  | % Effort
 | Role:  [    ] PI      [     ]  Co-PI     [     ]  Investigator
 | Funding Agency:      [     ]  National     [     ]  Local |  |  |  |  |  | $ [NAME]
 | Entire period of [NAME]:
 | Total Award:  $ ___________________
 | Indirect Cost Rate:   _________%
 | GRANTS AND CONTRACTS (continued)
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Grant  [      ]               Contract  [       ] |  | Submitted/ |  | New or | Current | Salary
 |  |  | Not Funded/ | Continu- | Competing | Year | Covered
 | Title: __________________________________________ |  | Pending | ation | Renewal | Budget | by G&C
 |  |  |  |  |  |  | % Effort
1.
 | Role:  [    ] PI      [     ]  Co-PI     [     ]  Investigator
 | Funding Agency:      [     ]  National     [     ]  Local |  |  |  |  |  | $ [NAME]
 | Entire period of [NAME]:
 | Total Award:  $ ___________________
 | Indirect Cost Rate:   _________%
 |  |  | [a] | [b] | [c] | [d] | [e]
 | Grant  [      ]               Contract  [       ] |  | Submitted/ |  | New or | Current | Salary
 |  |  | Not Funded/ | Continu- | Competing | Year | Covered
 | Title: __________________________________________ |  | Pending | ation | Renewal | Budget | by G&C
 |  |  |  |  |  |  | % Effort
 | Role:  [    ] PI      [     ]  Co-PI     [     ]  Investigator
 | Funding Agency:      [     ]  National     [     ]  Local |  |  |  |  |  | $ [NAME]
 | Entire period of [NAME]:
 | Total Award:  $ ___________________
 | Indirect Cost Rate:   _________%
 | OTHER.  [Include all other research activities during this review period that are not included above, e.g.,
 | unfunded research, collaborative research with others outside MSM.]
 |  |  | Departmental Resources Used [e.g., space,
 | Briefly Describe Nature of Research |  | equipment, personnel.]
2.
 | PUBLICATIONS.  [List only those published or in press during this review period (July 1, 2005 - June 30, 2006).]
 | A.  Manuscripts/Book Chapters/Reviews
 | Full Citation
3. | A.  Peer Reviewed
 | [NAME]
 | C.  Book Chapter
 | D.  Reviewed /Other
 | Total Manuscripts
 | B. Abstracts [List abstracts during this review period and check applicable columns at right.]
 | Full Citation |  |  | Platform | Poster | National | Local
 | Total Abstracts
4. | OTHER SCHOLARLY/PROFESSIONAL ACTIVITY |  |  |  |  | % Effort _______
 | A.  Other.  [List all other scholarly/professional activities during this review period that are not listed above, e.g.,
 | letters to the editor.]
 | A. Invited Presentations
 | 1.  Internal
 | 2.  External
 | B.  Paper or Poster Presentation
 | 1.  Internal
 | 2.  External
 | C.  Other
 | This section to be completed for clinical activities that DO NOT INVOLVE STUDENTS OR RESIDENTS.  To arrive at
 | the TOTAL NUMBER per year, multiply the columns identified in brackets next to the activity below.]
 |  |  | [a] | [b] | [c] | [d] | [e]
 |  |  | # of | # of | # of | # of | Total
 | Direct Patient Care |  | Sessions | Weeks | Days | Months | Number
 | (No students or residents present) | Location | Per Wk | Per Mo | Per Yr | Per Yr | Per Year
 | 1/2 day clinic  [a x b x d]
 | 1/2 day procedures  [a x b x d]
 | On Call at Home -- one day [c]
 | On Call in Hospital -- one day [c]
 | Operating Room - one day [c]
D.
 | Total Effort = A + B + C + D |  |  |  | Total % Effort _______