POSTDOCTORAL ACTIONS FORM
Dean of the Faculty, Office of Faculty Personnel
Dean of the Biomed, Office of Medical Faculty Affairs
1. Name:
2. Department:
3. Contact Person:
4. Supervising faculty member:
5. Reason for Request:
New Appointment Extension
Replacement for Title Change
New position Salary Change
Reappointment
6. Title:
Postdoctoral Research Associate
Postdoctoral Fellow
50% Postdoctoral Fellow/50% Postdoctoral Research Associate
7. Term of Appointment: From to
Appointments may be made for a maximum of 1 year and are renewable yearly for no more than 5 years.
8. Previous Term of Appointment as Postdoc: From to
9. Salary (for Postdoc Research Associates) or Stipend (for Postdoc Fellows):
Salary Amount: Account Number:
Name of Grant:
Stipend Amount: Account Number:
Name of Fellowship:
10. [for Postdoctoral Fellows only] If source of benefits funding is different from the account listed
for the stipend, please list it here:
11. Visa Status
Needs J-1 Visa (please attach DS-2019 Application Form)
Holds H Visa / H Visa Pending
Begin Date: End Date:
Holds F Visa with OPT / OPT Pending
Begin Date: End Date:
___________________________________ _______________
Signature of sponsor/supervisor Date
PLEASE SEE THE ATTACHED DOCUMENT, “Information for Postdoctoral Fellows and
Postdoctoral Research Associates,” for additional information. 10/18/05