MIQS Organic Faculty Appointment Form-3775715

Faculty Appointment Application Form

MedStar Institute for Quality and Safety

Name*

First Name

Last Name

Phone*

Email Address*

Title*

Primary Department*

What type of MIQS appointment are you applying for?*

Core Faculty Associate Faculty Affiliate Faculty Adjunct Faculty

If you are applying for an appointment as Adjunct Faculty, please provide the name of your MIQS core faculty sponsor:

Select up to 3 MIQS Centers of Expertise you are most interested in working with*

Center for Open & Honest Communication International Training Center for Bloodless Medicine & Surgery Center for Engaging Patients as Partners Center for Improving Diagnosis in Healthcare Center for Healthcare Narratives Center for Integrated Healthcare Learning Center for Patient Safety and Quality Research

Why you are interested in an appointment with the MedStar Institute for Quality and Safety?*

In 250 words or less, please explain.

What are your specific areas of interest within patient safety and quality of care?*

In 250 words or less, please explain.

After you submit this form, please forward your current CV and a brief letter of support for this faculty appointment from your division/department/school/core faculty sponsor to miqsinfo@medstar.net to complete your application process.

This form is secured and the information that you provide is confidential.

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