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					                                       Documentation of Faculty Credentials
                                           Pittsburg State University

This form documents that instructional faculty meet HLC qualifications for teaching. The form must be
completed for all new full-time and part-time employees as well as reappointments who will be listed as
instructors of record.

Section 1: Employee Information

College:                                           Department:
Faculty Member’s Last Name:                                        First Name:
Academic Rank:
Check all that Apply:         Tenured/Tenure Earning             Full-time Temporary          Part-time Temporary

Section 2: Earned Degree Information

Earned Degree           Discipline               Institution                       Year          Official
(Highest First)                                                                    Degree        Transcript on
                                                                                   Received      File

Section 3: Course(s) to be taught:

Section 4: Eligibility
Basis for Qualification (Check One)                Graduate Degree in Major
                                                   Additional Qualifications at the Time of Initial Hire

If basis for eligibility is additional qualifications, please check all that apply and attach documentation:
         Degree from related discipline                             Research and Publications
         Professional Licensure or Certification                    Special Training
         Related Work Experience                                    Documented Teaching Excellence in Discipline
         Honors, Awards, or Special Recognition                     Other Competencies or Achievements

Justification Narrative:

Department Chair Signature:                                                Date:

Dean Signature:                                                            Date:

Provost Signature:                                                         Date:

EO/AA Director Signature:                                                  Date:

(Form date: 7/5/12)

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