Application - Pacific University

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					                                                    Adjunct Faculty Application

Last name _______________________________________ First ____________________________________________ M.I. ____________

Street address_____________________________________________________________________________________________________

City ____________________________________________________ State ___________________ Zip code ________________________

Email address _____________________________________________________________________________________________________

Telephone: (home) ____________________________ (work) ______________________________ (cell) ___________________________

Place of employment _______________________________________________________________________________________________

Title _____________________________________________________________________________ Years there ______________________

AOTA Member # ______________________________________ OTAO Member # _____________________________________________

Licensure Information: _____________________________________________________________________________________________

POSITION INTEREST:

__ Guest Lecturing (1-3 hour commitment)

    Guest Teaching Special Units (e.g., a three-class unit on splinting to a one month course on advanced pediatric practice)

    Laboratory teaching assistants (weekly commitments of 6-8 hours in foundational OT process courses for a full 15 week semester)

    Innovative Practice Project supervision (providing 3-10 hours per week of on-site supervision for the development of emerging practice model
    with student teams of 2-4 students)

   Level I fieldwork supervision in community-based psychosocial or pediatric settings, and serving as an on-line course discussion leader on topics
   in your practice area.



REQUIRED DOCUMENTS FOR APPLICATION: In addition to this application, please attach a cover letter, resume, and copies of your graduate and
undergraduate transcripts to:


                                                 John White, Program Director
                                                 School of Occupational Therapy
                                                 Pacific University
                                                          th
                                                 190 SE 8 Ave., Suite 360
                                                 Hillsboro, OR 97123
                                                 ot@pacificu.edu

Application materials will be screened and interview candidates will be selected and notified. The hiring process normally consists of several
interviews and can last several weeks depending on the position. Employment is contingent upon eligibility to work in the United States and
successful completion of a background check. Candidates that hold current memberships in OTAO and AOTA, and have a record of continuing
education and/or conference presentations are preferred. If the position is posted on our job board at
http://www.pacificu.edu/hr/employment/positions/index.cfm it is an available position and you may apply. No phone calls please.

Pacific University was founded in 1849 with its historic campus in Forest Grove, and now includes campuses in Hillsboro, Portland and Eugene. With
a rich liberal arts tradition in the College of Arts and Sciences and acclaimed Colleges of Education, Health Professions and Optometry, Pacific
University presents a distinctive combination of learning opportunities. The Forest Grove campus focuses on liberal arts, education and optometry
offerings. Additional College of Education programs are offered at a satellite campus in Eugene. The Hillsboro Health Professions Campus offers
professional programs in dental health (dental hygiene), gerontology, healthcare administration, occupational and physical therapy, pharmacy,
professional psychology, optometry and physician assistant studies. Additional facilities in Portland support the clinical programs of the College of
Optometry and the School of Professional Psychology. Pacific is committed to a tradition of service and support to the community, offering service
learning, international education, internship, research opportunities and co-curricular activities to students and faculty. Approximately 3,300
students enjoy a rigorous academic experience, professors who love to teach and a warm, welcoming atmosphere where their lives unfold.

NOTICE OF NONDISCRIMINATION POLICY | It is the policy of Pacific University not to discriminate on the basis of sex, physical or mental disability,
race, color, national origin, sexual orientation, age, religious preference or disabled veteran or Vietnam Era status in admission and access to, or
treatment in employment, educational programs or activities as required by Title IX of the Education Amendments of 1972, section 504 of the
Rehabilitation Act of 1973, Title VII of the Civil Rights Act of 1964, the Age Discrimination Act, the Americans with Disabilities Act of 1990, or any
other classification protected under state or federal law, or city ordinance. Questions or complaints may be directed to the Vice President for
Academic Affairs, 2043 College Way, Forest Grove, OR 97116, 503-352-2215.

                                                            Educational background

Graduate degree _____________________ Institution ___________________________________________ Year conferred ___________________
Area of specialty ___________________________________________________________________________________________________________

Graduate degree _____________________ Institution ___________________________________________ Year conferred ___________________
Area of specialty ___________________________________________________________________________________________________________

Undergraduate degree _________________ Institution ___________________________________________ Year conferred ___________________
Area of specialty ___________________________________________________________________________________________________________

Other institutions attended: Institution________________________________________________________ Year(s) attended__________________
                              Institution________________________________________________________ Year(s) attended__________________


                                                           Professional certifications
                          PLEASE PROVIDE US WITH COPIES OF CERTIFICATES YOU HOLD APPLICABLE TO YOUR TEACHING

Type _______________________________ Term ________________________________________ Certificate # _____________________________
Issuing Organization ________________________________________________________________________________________________________

Type _______________________________ Term ________________________________________ Certificate # _____________________________
Issuing Organization ________________________________________________________________________________________________________


Type _______________________________ Term ________________________________________ Certificate # _____________________________
Issuing Organization ________________________________________________________________________________________________________


                                                              Teaching experience
                Course Title                                                School                                               Term
 _________________________________________                  ________________________________________                   _________________________
 _________________________________________                  ________________________________________                   _________________________
 _________________________________________                  ________________________________________                   _________________________
 _________________________________________                  ________________________________________                   _________________________
 _________________________________________                  ________________________________________                   _________________________
  _________________________________________               ________________________________________     _________________________
Are you interested in teaching:       ☐online         ☐classroom      ☐both
Do you have experience teaching in an online delivery method?     ☐yes      ☐no
If yes, platform(s) you have used ______________________________________________________________________________________________
Teaching availability:
Terms available to teach: Fall______ Winter/Spring:_______ Summer________
                                                         Other related experience



Approximate number of fieldwork students supervised: Level I ________ Level II _________ Date of last FW student ________________________

                                                          Professional references
Name ______________________________________ Title ____________________________________ Company ___________________________
Email _______________________________________ Phone ______________________________________________________________________

Name ______________________________________ Title ____________________________________ Company ___________________________
Email _______________________________________ Phone ______________________________________________________________________

Name ______________________________________ Title ____________________________________ Company ___________________________
Email _______________________________________ Phone ______________________________________________________________________
                                                 Courses you feel qualified to teach

                        Refer to the Pacific University School of OT Catalog for Exact Course Information
                                               At http://www.pacificu.edu/catalog

Note: Complete course information is required in order to obtain approval to teach
                                                                                             Department Chair Approval

Course Number ___________________                                                            ☐Yes     ☐No                   Initial

Course Title ____________________________________________________________________            Date: __________            __________

Course Number ___________________                                                            ☐Yes     ☐No                   Initial

Course Title ____________________________________________________________________            Date: __________            __________

Course Number ___________________                                                            ☐Yes     ☐No                   Initial

Course Title ____________________________________________________________________            Date: __________            __________

Course Number ___________________                                                            ☐Yes     ☐No                   Initial

Course Title ____________________________________________________________________            Date: __________            __________

Course Number ___________________                                                            ☐Yes     ☐No                   Initial

Course Title ____________________________________________________________________            Date: __________            __________

Course Number ___________________                                                            ☐Yes     ☐No                   Initial

Course Title ____________________________________________________________________            Date: __________            __________

Course Number ___________________                                                            ☐Yes __________ ☐No         Initial

Course Title ____________________________________________________________________            Date: __________            __________

Topics in which you could serve as guest lecturer: ______________________________________________________________________________

Topics you could instruct in applied lab sections: _______________________________________________________________________________
                                                            Applicant’s statement
1.   Can you provide proof of eligibility to work in the U.S.:        ☐Yes                ☐No
2.   Have you plead guilty or been convicted of a felony within ten years
     preceding your application to Pacific University?                ☐Yes                ☐No

     If your answer is Yes, please provide us with the state and county or other jurisdiction or the plea or conviction, the felony to which you were
     convicted or to which you plead guilty, and the case number of the prosecution. You may also provide any additional factual information you
     feel would be helpful.




3.   Are you capable, with or without reasonable accommodation, of performing the activities involved in the job or occupation for which you have
     applied? (Note: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.)
     ☐Yes          ☐No http://www.pacificu.edu/ot/students/documents/4-OT-Student-Job-Description-8-2-2010.pdf

I certify that the answers given herein are complete to the best of my knowledge. I authorize investigation of all statements contained in this
application for employment as many be necessary in arriving at an employment decision. In the event of employment, I understand that false or
misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules
and regulations of the employer. I agree to provide official transcripts of my postsecondary degrees upon employment.


Signature _________________________________________________________________ Date Submitted __________________________________
                                     Adjunct faculty evaluation/ Course approval
                                            TO BE COMPLETED BY PACIFIC UNIVERSITY


Administrative interview         Comments _______________________________________________________________________________
                                  ________________________________________________________________________________________
                                  __________________________________________ Rating: ☐Excellent   ☐Good       ☐Fair ☐ Poor
                                 Signature _______________________________________________________ Date ____________________


Department Director              Comments _______________________________________________________________________________
☐ Approved                        ________________________________________________________________________________________
☐ Denied                          __________________________________________ Rating: ☐Excellent   ☐Good       ☐Fair ☐ Poor
                                 Signature _______________________________________________________ Date ____________________


Faculty Member                   Comments _______________________________________________________________________________
☐ Approved                        ________________________________________________________________________________________
☐ Denied                          __________________________________________ Rating: ☐Excellent   ☐Good       ☐Fair ☐ Poor
                                 Signature _______________________________________________________ Date ____________________


Faculty Member                   Comments _______________________________________________________________________________
☐ Approved                        ________________________________________________________________________________________
☐ Denied                          __________________________________________ Rating: ☐Excellent   ☐Good       ☐Fair ☐ Poor
                                 Signature _______________________________________________________ Date ____________________



                                             Phone contact with references
Call made by ____________________________________________________________________________________ Date ____________________
Reference name __________________________________________________________________________________________________________
Association with applicant __________________________________________________________________________________________________
Comments_______________________________________________________________________________________________________________




Call made by ____________________________________________________________________________________ Date ____________________
Reference name __________________________________________________________________________________________________________
Association with applicant __________________________________________________________________________________________________
Comments_______________________________________________________________________________________________________________




Call made by ____________________________________________________________________________________ Date ____________________
Reference name __________________________________________________________________________________________________________
Association with applicant __________________________________________________________________________________________________
Comments_______________________________________________________________________________________________________________

				
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