University of Pittsburgh | UPMC | Health Sciences at Pitt | School of Medicine



2018 Leadership Academy for Early Career Faculty

At the end of this form you will be required to upload your letter of nomination and your current CV together in one field. Both files should be located in the same directory on your PC so you can locate and choose each of them when you are ready to upload. Make sure you have both prepared for upload before you complete this form or you will not be able to submit your application and you cannot save the form for completion at a later time. The deadline to apply is December 20, 2017.

Have you previously attended a leadership course?
If yes, please select:
Please specify other:
Name and E-mail
First: Middle Initial: Last:
Gender Self-Identify Gender:
Ethnicity
Please select all that apply
Race

E-mail:
Work Street Address:
Building:
Room:
City: State: Zip:
Campus phone: -
Cell phone: -
Select Your Highest Degree
Select your primary academic classification
Current Position and Titles:
Title 1:
Title 2:
Title 3:
Department:
Division:
School of:
Nominated by (including title & affiliation):
(Must be nominated by Department Chair, Division Chief, Center/Institute Director, or Dean)
First: Middle Initial: Last:
Title:
Department:

I will commit to attending all of the planned sessions:


Please indicate your faculty rank:
Please specify other:
Are you currently in a leadership capacity?
If yes, please indicate title:
If you are an investigator, are you currently the principal person responsible for managing your laboratory or research program?
How many people are you responsible for supervising in your laboratory or research environment?

Fellows:

Graduate & undergrad. students:

Research staff:

If you are an educator, how many years have you been teaching?

What do you hope to accomplish by enrolling in this program? Please note that the thoughtfulness of your response will be a key factor in consideration for acceptance into the program. (Limit 200 words)
Please attach your letter of nomination and your current CV. Sponsors should indicate how the applicant will be paying for the course, e.g., departmental funds, professional development fund, or personal funds. Nomination letters should be addressed to Leadership Academy Admissions Committee, University of Pittsburgh, 301 Scaife Hall, Pittsburgh, PA 15261.

Both files should be uploaded at the same time. You can select multiple files by holding in the Ctrl key on your keyboard while clicking on the two files you wish to upload.

Upload your letter and CV (.PDF, .DOC or .DOCX only)