Faculty Fact Sheet

Name: Position:
Employed By: Title:

Proportion of time in:
Teaching: % Administration: % Clinical Services: %

Institution Field of Study Degree Year


Certified by:

Certification #: Year Certified:


Experience (List current position first):

Institution/City/State Position Year


List principal functions in the education program:


List continuing education activities during the past three years:

Title Sponsor Date

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