FACULTY SERVICE REVIEW FORM

CALENDAR YEAR _______

The Faculty Service Review Form is intended to provide the necessary background information needed for annual performance evaluation by the unit head and to provide the information needed by the Bumpers College, Agricultural Experiment Station and Cooperative Extension Service administration for annual accountability reporting.

I.	Appointment

Name:

Rank:

Department:

A.	Date and rank of first appointment:

B.	Date of appointment to present rank:

C.	Years of service in present rank, including the present year:

D. Budgeted time for your salary:

%

Teaching	%

Research	%

Extension	%

Service	%

Administration

E.	Teaching, research, extension and service ASSIGNMENTS for calendar year (as determined on your annual assignment not necessarily as budgeted within the unit):

%

Teaching	%

Research	%

Extension	%

Service	%

Administration

F. Executive Summary – Please provide a brief summary (2 pages maximum) of your significant teaching, research, extension, service and/or administration accomplishments for the calendar year.

II. Measurable Accomplishments in Teaching, Research, Extension, and Service

Publications

Include citation for only those articles that have been published, submitted, or in press. Articles submitted or in press should be indicated as such. Please bold your name and those of other UA co-authors.

Books, book chapters.

Peer-reviewed journal articles.

Other peer-reviewed publications (e.g. review articles, proceedings, etc).

Non-refereed publications and articles (e.g. proceedings, trade press, etc).

Published abstracts of conference presentations.

Extension publications and literature.

Professional Presentations (professional society meetings, seminars, teaching, research, or extension. Extension presentations to clientele are listed under Section V).

Invited presentations such as a plenary or keynote address, seminars, or other; indicate if presentation was refereed/reviewed).

Submitted/selected oral or poster presentations.

Other creative endeavors.

Honors, Awards and Recognitions.

Received by you and your program.

Received by your undergraduate or graduate students.

Support for teaching (T), research (R) or extension (E) program.

1.	Grants awarded.

Category

T,R,E

Investigators

Title

Agency/Source	Years Funded	Total Amt. ($)	Annual Amt. ($)	My Share This Year ($)

2.	Grants pending.

Category

T,R,E

Investigators

Title

Agency/Source	Years Funded	Total Amt.

($)	Annual Amt. ($)	Date Submitted

3.	Grants submitted but not funded.

Category

T,R,E

Investigators

Title

Agency/Source

Total Amt. ($)

4. Gifts and gifts-in-kind to your program.

Category

T,R,E

Title

Agency/Source	Years Provided	Estimated Value ($)

5. Other program support not listed above.

Category

T,R,E

Title

Agency/AES

Years Funded

Total Amt. ($)

Annual Amt. ($)	My Share

This year ($)

Graduate Education.

1.	Master’s or doctoral students directed but not yet finished. Indicate if MS students are thesis (T) or non-thesis (N) track.

Name

Degree	T

N	Expected Completion Date

2.	Master’s or doctoral students directed who completed their degree requirements during the calendar year.

Name

Degree	T

N	Expected Completion Date

3.	Master’s or doctoral committee memberships.

Name

Degree	T

N	Expected Completion Date

III.	Teaching and Advising - If none check here.

A.	Courses taught by semester.

Semester

Course Number

Title

% Responsibility

Co-instructors (if team taught)

Enrollment

Mean of Core Medians

Advising - Please attach your advising credit tabulation if utilized in your unit. Include total number of undergraduate students advised.

C.	Teaching effectiveness, innovation and improvement.

Provide information illustrating teaching or advising effectiveness student accomplishments as well as efforts to improve your instruction such as workshops, classroom innovations, and teaching portfolio development.

Indicate courses developed for platform or distance delivery during the year. (Indicate electronic format, locations of delivery, and audience)

D.	Other instructional or advising activities.

List other instructional and advising activities, such as student club advising, special problems directed, significant course revision, honors students supervised, guest/special lectures, or others as pertinent.

IV.	Research and Other Creative Activities - If none, check here.

Interdisciplinary and collaborative research.

List interdisciplinary research activities and collaborations that contribute to your overall program.

Indicate formal regional research collaborations such as participation in regional research projects, information exchange groups and other formal research collaborations.

Intellectual Property.

US Patents applications submitted. Include inventors, patent name, type, application date, and application number.

US Patents issued. Indicate inventors, patent name, type, issuance date, and number.

Copyrights applied for or obtained.

Other intellectual property protection applied for or obtained. (Include: international patent applications and those granted, PVPs, plant breeder’s rights, trademarks, invention disclosures and/or other forms of protection or agreements).

V.	Extension - If none, check here.

Program Planning – Describe planning efforts used to determine program content and priorities and highlight the outcomes. Include names of participants and methods used i.e. formal needs assessments, surveys, planning committees, and existing data.

Faculty and Staff Education/Assistance – Describe or list educational activities (e.g. in-service training, etc) conducted using a direct contact or electronic method to teach or assist Extension personnel.

Extension Clientele Educational Activities.

Meetings, workshops, tours, field days, etc. that you organized or played a major role in (indicate your role).

Individual Presentations (county, state, regional, national, etc) – indicate date, title, location).

Other Extension Educational Activities.

a.	Activities with Major Leadership Roles.

b.	Individual Presentations. (County, state, and/or regional meetings, etc)

Other Program Activities.

E.	Interdisciplinary or Multi-State Extension.

List interdisciplinary and/or multi-state extension activities and collaborations that contribute to your overall program. Indicate formal extension collaborations, such as participation in regional or national extension projects, information exchange groups, etc.

F.	Professional Improvement (indicate if not on official Extension time)

VI.	Service

Service to the University, Division of Agriculture, College or Department (include committee memberships and other identified service functions. Please indicate if you serve as chair of the committee).

Service to professional organizations (include offices held, committee appointments, journal editorships, manuscript reviews and other direct service to your professional organization).

Direct service to people, communities and other client groups directly related to your professional responsibility. Include service programs and consultation with institutions, local communities, and government agencies. Describe the service responsibility, client group or stakeholders, major collaborators, contribution made by you and impact from the activity. List activities and locations.

Other service activities.

VI.	Administrative Responsibilities - If none, check here.

A.	Briefly describe scope of supervisory assignment and percent administrative appointment as assigned by appropriate AVP.

B.	Personnel supervised in terms of FTE’s and institutional locations.

Faculty

Number	FTE’s	Location(s)

Classified and Non-Classified Staff

Number	FTE’s	Location(s)

Policy and Management Guidelines	PMGS03-9

Rev. 01/2012

1

Faculty Service Review Form

Faculty Service Review Form

faculty, service, review, department

David Hensley

2012-02-15

uaex

U of A Fayetteville