TEACHING & EDUCATION REPORT
[Given Name] [Family Name]
University of Toronto
Introduction
[Introduction to TER]
Teaching Philosophy
[Teaching Philosophy]
Teaching Landmarks
[Start - End Dates]
Teaching Awards	
	[Start – End Dates]	[Award Name], [Institution / Organization] ([Award Status])	
Research in Education	
	[Start – End Dates]	[Title/Subject].	
Innovations and Development in Teaching and Education		Total Hours	
	[Start – End Dates]	[Title], [Primary Audience], [Faculty], [University Department], [Division], [Institution / Organization].	[00]	
Leadership in Education	
	[Institution/Organization]	
	[Start – End Dates]	[Title/Position]. [Faculty], [Department], [Division], [City], [Province/State], [Country]. ([Type]) 	
Administrative Service in Education	Total Hours 	
	[Institution/Organization]	
	 [Start  End Dates]	 [Role], [Committee Name], [Educational Level], [Faculty], [University Department], [Division], [City], [Province / State], [Country]. 	[00]	

I. Multilevel Education (Teaching Events with Multiple Levels of Trainees)
1)	Academic Year [Start - End Date]
a)	Teaching Awards
Received	
 [Start – End Dates]	 [Award Name], [Faculty], [University Department], [Division], [Institution/Organization], [City], [Province/State], [Country].
[Description of Award].	
Nominated	
		
b)	Innovations and Development in Teaching and Education
[Start – End Dates]	[Title].
[Faculty], [University Department], [Division], [Institution / Organization]. 
[Description].
[Impact].
Total Hours: [00]	
Total number of hours: 	[00]	
c)	Leadership in Education
[Institution/Organization]	
[Start – End Dates]	[Title/Position]. [Faculty], [Department], [Division], [City], [Province/State], [Country]. ([Type])
[Description].	
d)	Administrative Service in Education
[Institution / Organization]	
[Start - End Dates]	 [Role], [Committee Name], [Faculty], [University Department], [Division], [City], [Province / State], [Country]. 
 [Description] 
 Total Hours for Entire Activity: [00] 	
Total number of hours: 	[00]	
e)	Aggregate Teaching Evaluations
[Start – End Dates]	 [Source]. [Faculty], [University Department], [Division],
 Number of Student Evaluations: [00]
 Teaching Evaluation Score (Individual Mean): [00]
 City Wide Mean: [00]
 Hospital Mean: [00]
 Division Mean: [00]
 Quintile: [00]
Evaluation Details: [Student Comments]
	
f)	Departmental Education

Lectures
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Seminars
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Small Group or PBL Teaching
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Workshops
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Examinations
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Teaching Rounds
Formal Teaching Rounds (Scheduled Centrally)	
 [Start - End Dates]	Title: [Course Title]. [Department], [Division]. Location of Teaching: [Location]
Description: [Optional description]
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students for Formal Teaching Rounds: 	[00]	
Total Number of Hours for Formal Teaching Rounds: 	[00]	
Informal Teaching Rounds (Scheduled by Teacher)	
 [Start - End Dates]	Title: [Course Title]. [Department], [Division]. Location of Teaching: [Location]
Description: [Optional description]
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students for Informal Teaching Rounds: 	[00]	
Total Number of Hours for Informal Teaching Rounds: 	[00]	

Simulations
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Labs
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Practicum
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Individual Consultations
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Peer Coaching
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Remediation
[Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Other Teaching Activities (user defined)
 [Start – End Dates]	 [Activity Title], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Clinical Supervision
Assigned	
[Start – End Dates]	 [Role], [Faculty], [University Department], [Division]. Location of Teaching: [Location of teaching]. 
 [Activity Description].
Number of Students: [Number of Students]
Unit: [No. of Units] X [Type of Units]
Total Hours: [Total Hours]
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
Total Number of Multilevel Clinical Students Supervised:	[00]	
Total Number of Clinical Supervision Hours:	[00]	
Elective	
[Start – End Dates]	 [Role], [Faculty], [University Department], [Division]. Location of Teaching: [Location of teaching]. 
 [Activity Description].
Student Name(s): 
 a. [Student Level]: [Student Name]; [Student Name]. 
 b. [Student Level]: [Student Name]; [Student Name]. 
Number of Students: [Number of Students]
Unit: [No. of Units] X [Type of Units]
Total Hours: [Total Hours]
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
Total Number of Multilevel Clinical Students Supervised:	[00]	
Total Number of Clinical Supervision Hours:	[00]	

Research Supervision
[Start – End Dates]	 [Role], [Faculty], [University Department], [Division].
 Student Details: [Student Name], Student’s Current Position: [Student’s Current Position], Student’s Current Institution: [Student’s
 Current Institution]
 Degree: [Year/Stage], [Degree / Program of Study]
 Research Project: [Research Project Title]
 Awards: [Student Awards Attained]
 Collaborators: [Collaborators]
 Completed: [YYYY]
 Total Hours: [00]
 [Description].	
Total Number of Multilevel Research Students Supervised:	[00]	
Total Number of Research Supervision Hours:	[00]	

Mentorship/Preceptorship
[Start – End Dates]	[Type of Mentee / Preceptorship], [Mentee Name], [Institution of Mentee], [Mentee Title / Position], [Year/Stage].
[Faculty], [University Department], [Division]. ([Formal], No. of Encounters per Year: [00], Total Hours: [00])
[Mentor Purpose / Responsibilities].	
Total Number of Multilevel Students Mentored:	[00]	
Total Number of Mentorship Hours:	[00]	

g)	Interdepartmental Education (Within Faculty of Medicine)
Same format as in f) Departmental Education above.
h)	Inter-faculty Education
Same format as in f) Departmental Education above.
i)	Education Outside the University and its Affiliated Hospitals)
Same format as in f) Departmental Education above.
j)	Postgraduate, Research and Specialty Training
[Start – End Dates]	[Title/Position], [Subject/Discipline], [Department/Program], [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor].	
k)	Qualifications, Certifications and Licenses
[Start – End Dates]	[Title], [Speciality], [Institution/Organization], [City], [Province/State], [Country], License / Membership #: [License / Membership #].	
l)	 Honours and Career Awards
Received	
[Start – End Dates]	[Award Name], [Faculty], [University Department], [Division], [Institution/Organization], [City], [Province/State], [Country]. ([Award Type], Specialty: [Specialty]. [Educational Level], [Year/Stage])
Awardee Name: [Student Name].
Role: [Role]
Total Amount: [Total Amount] [Currency]
[Description of Award].	
Nominated	
		
m)	Other Noteworthy Activities
[Start – End Dates]	Type: [Type]. Audience: [Audience]. [City], [Province/State], [Country].
[Description].
Results / Evaluation: [Results/Evaluation]	
n)	Patents and Copyrights
[Date of Issue]	[Title]. [Type], [Status]. (Patent or Copyright ) #: [Patent/Copyright #], [Country], Joint Holder Names: [Joint Holder Names].
[Brief Description].	
o)	Grants, Contracts and Clinical Trials
Funded	
[Start – End Dates]
	[Role]. [Title]. [Funding Source], [Funding Program Name], [Grant and/or Account #]. PI: [Principal Investigator]. Collaborators: [Collaborators]. ([Funding Type]).
Total Amount: [Total Grant Amount] [Currency].
[Description].	
Declined	
		
p)	Salary Support and Other Funding
Personal Salary Support	
[Start – End Dates]
	[Funding Title], Trainee Name: [Student Name], [Funding Source], [City], [Province/State], [Country]. Specialty: [Specialty].
Total Amount: [Total Amount] [Currency].	
Trainee Salary Support	
		
q)	Publications
Journal Articles	
[Authors]. [Title]. [Rest of Citation]. [Publication Status]. Impact Factor: [Journal Impact Factor]. [Trainee Publication]. [Trainee Details]. [Role].
[Most Significant Publication]. [Most Significant Publication Details].	
Case Reports	
	
Abstracts 	
	
Books	
	
Books Edited	
	
Book Chapters	
	
Manuals	
	
Editorials	
	
Monographs	
	
Websites / Videos	
	
r)	Presentations
International	
[Date]	[Role]. [Presentation Type]. [Title]. [Host], [City], [province/State], [Country]. Presenter(s): [Presenters]. [Rest of Citation]. ([Presentation by Trainee])
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
National	
		
Regional / Provincial	
		
Local	
		
s)	Peer Review Activities
Associate or Section Editing	
[Start – End Dates]	[Role]. [Institution/Organization], [Journal/Section], Number of Reviews: [Number of Reviews]	
Editorial Boards	
		
Grant Reviews	
		
Manuscript Reviews	
		
Presentation Reviews	
		
t)	Other Research and Professional Activities
Research Projects	
[Start – End Dates]	[Role]. [Contribution Area]. [Title]. [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor]. Collaborator(s): [Collaborators].	
Thesis Projects	

II. Undergraduate Education
1)	Academic Year [Start - End Dates]
a)	Teaching Awards
Received	
 [Start – End Dates]	 [Award Name], [Faculty], [University Department], [Division], [Institution/Organization], [City], [Province/State], [Country].
[Description of Award].	
Nominated	
		
b)	Innovations and Development in Teaching and Education
[Start – End Dates]	[Title].
[Faculty], [University Department], [Division], [Institution / Organization]. 
[Description].
[Impact].
Total Hours: [00]	
Total number of hours: 	[00]	
c)	Leadership in Education
[Institution/Organization]	
[Start – End Dates]	[Title/Position]. [Faculty], [Department], [Division], [City], [Province/State], [Country]. ([Type])
[Description].	
d)	Administrative Service in Education
[Institution / Organization]	
[Start - End Dates]	 [Role], [Committee Name], [Faculty], [University Department], [Division], [City], [Province / State], [Country]. 
 [Description] 
 Total Hours for Entire Activity: [00] 	
Total number of hours: 	[00]	
e)	Aggregate Teaching Evaluations
[Start – End Dates]	 [Source]. [Faculty], [University Department], [Division],
 Number of Student Evaluations: [00]
 Teaching Evaluation Score (Individual Mean): [00]
 City Wide Mean: [00]
 Hospital Mean: [00]
 Division Mean: [00]
 Quintile: [00]
Evaluation Details: [Student Comments]	
f)	[Year/Stage]
Departmental Education
Seminars / Lectures
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Small Group or PBL Teaching
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Workshops
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Examinations
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Teaching Rounds
Formal Teaching Rounds (Scheduled Centrally)	
[Start - End Dates]	[Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students for Formal Teaching Rounds: 	[00]	
Total Number of Hours for Formal Teaching Rounds: 	[00]	
Informal Teaching Rounds (Scheduled by Teacher)	
[Start - End Dates]	[Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students for Informal Teaching Rounds: 	[00]	
Total Number of Hours for Informal Teaching Rounds: 	[00]	

Simulations
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Labs
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Practicum
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Individual Consultations
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Peer Coaching
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Remediation
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Other Teaching Activities (user defined)
[Start – End Dates]	 [Activity Title], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
 [Activity Description].
Total Hours for Entire Activity: [00]
Total Number of Students: [00]
Teaching Evaluation Score: [00]
Evaluation Details: [Evaluation Details]	
Total Number of Students: 	[00]	
Total Number of Hours: 	[00]	

Clinical Supervision
Assigned	
[Start – End Dates]	 [Role], [Faculty], [University Department], [Division]. Location of Teaching: [Location of teaching]. 
 [Activity Description].
Number of Students: [Number of Students]
Unit: [No. of Units] X [Type of Units]
Total Hours: [Total Hours]
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
Total Number of Undergraduate Clinical Students Supervised:	[00]	
Total Number of Clinical Supervision Hours:	[00]	
Elective	
[Start – End Dates]	 [Role], [Faculty], [University Department], [Division]. Location of Teaching: [Location of teaching]. 
 [Activity Description].
Student Name(s):  Student Name]; [Student Name]. 
Number of Students: [Number of Students]
Unit: [No. of Units] X [Type of Units]
Total Hours: [Total Hours]
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
Total Number of Undergraduate Clinical Students Supervised:	[00]	
Total Number of Clinical Supervision Hours:	[00]	

Research Supervision
[Start – End Dates]	 [Role], [Faculty], [University Department], [Division].
 Student Details: [Student Name], Student’s Current Position: [Student’s Current Position], Student’s Current Institution: [Student’s
 Current Institution]
 Degree: [Degree / Program of Study]
 Research Project: [Research Project Title]
 Awards: [Student Awards Attained]
 Collaborators: [Collaborators]
 Completed: [YYYY]
 Total Hours: [00]
 [Description].	
Total Number of Undergraduate Research Students Supervised:	[00]	
Total Number of Research Supervision Hours:	[00]	

Mentorship/Preceptorship
[Start – End Dates]	[Type of Mentee / Preceptorship], [Mentee Name], [Institution of Mentee], [Mentee Title / Position].
[Faculty], [University Department], [Division]. ([Formal], No. of Encounters per Year: [00], Total Hours: [00])
[Mentor Purpose / Responsibilities].	
Total Number of Undergraduate Students Mentored:	[00]	
Total Number of Mentorship Hours:	[00]	
Extra-Departmental Education (Within Faculty of Medicine)
Same format as Departmental Education for this level
Extra-Faculty Education
Same format as Departmental Education for this level
Extra-University Education (Outside U of T)
Same format as Departmental Education for this level
g)	Postgraduate, Research and Specialty Training
[Start – End Dates]	[Title/Position], [Subject/Discipline], [Department/Program], [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor].	
h)	Qualifications, Certifications and Licenses
[Start – End Dates]	[Title], [Speciality], [Institution/Organization], [City], [Province/State], [Country], License / Membership #: [License / Membership #].	
i)	 Honours and Career Awards
Received	
[Start – End Dates]	[Award Name], [Faculty], [University Department], [Division], [Institution/Organization], [City], [Province/State], [Country]. ([Award Type], Specialty: [Specialty]. [Educational Level], [Year/Stage])
Awardee Name: [Student Name].
Role: [Role]
Total Amount: [Total Amount] [Currency]
[Description of Award].	
Nominated	
		
j)	Other Noteworthy Activities
[Start – End Dates]	Type: [Type]. Audience: [Audience]. [City], [Province/State], [Country].
[Description].
Results / Evaluation: [Results/Evaluation]	
k)	Patents and Copyrights
[Date of Issue]	[Title]. [Type], [Status]. (Patent or Copyright ) #: [Patent/Copyright #], [Country], Joint Holder Names: [Joint Holder Names].
[Brief Description].	
l)	 Grants, Contracts and Clinical Trials
Funded	
[Start – End Dates]
	[Role]. [Title]. [Funding Source], [Funding Program Name], [Grant and/or Account #]. PI: [Principal Investigator]. Collaborators: [Collaborators]. ([Funding Type]).
Total Amount: [Total Grant Amount] [Currency].
[Description].	
Declined	
		
m)	Salary Support and Other Funding
Personal Salary Support	
[Start – End Dates]
	[Funding Title], Trainee Name: [Student Name], [Funding Source], [City], [Province/State], [Country]. Specialty: [Specialty].
Total Amount: [Total Amount] [Currency].	
Trainee Salary Support	
		
n)	Publications
Journal Articles	
[Authors]. [Title]. [Rest of Citation]. [Publication Status]. Impact Factor: [Journal Impact Factor]. [Trainee Publication]. [Trainee Details]. [Role].
[Most Significant Publication]. [Most Significant Publication Details].	
Case Reports	
	
Abstracts 	
	
Books	
	
Books Edited	
	
Book Chapters	
	
Manuals	
	
Editorials	
	
Monographs	
	
Websites / Videos	
	
o)	Presentations
International	
[Date]	[Role]. [Presentation Type]. [Title]. [Host], [City], [province/State], [Country]. Presenter(s): [Presenters]. [Rest of Citation]. ([Presentation by Trainee])
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
National	
		
Regional / Provincial	
		
Local	
		
p)	Peer Review Activities
Associate or Section Editing	
[Start – End Dates]	[Role]. [Institution/Organization], [Journal/Section], Number of Reviews: [Number of Reviews]	
Editorial Boards	
		
Grant Reviews	
		
Manuscript Reviews	
		
Presentation Reviews	
		
q)	Other Research and Professional Activities
Research Projects	
[Start – End Dates]	[Role]. [Contribution Area]. [Title]. [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor]. Collaborator(s): [Collaborators].	
Thesis Projects	

III. Graduate Education
Same format as  II. Undergraduate Education above.

IV. Undergraduate MD
Same format as II. Undergraduate Education above.

V. Postgraduate MD
Same format as II. Undergraduate Education above.

VI. Continuing Education
Same format as I. Multilevel Education above.

VII. Faculty Development
Same format as I. Multilevel Education above.

VIII. Patient and Public Education
Same format as I. Multilevel Teaching above.

X. Related Educational Activities
1)	Academic Year [Start - End Date]
a)	Postgraduate, Research and Specialty Training
[Start – End Dates]	[Title/Position], [Subject/Discipline], [Department/Program], [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor].	
b)	Qualifications, Certifications and Licenses
[Start – End Dates]	[Title], [Speciality], [Institution/Organization], [City], [Province/State], [Country], License / Membership #: [License / Membership #].	
c)	Leadership in Education
Clinical	
[Start – End Dates]	[Title/Position]. [Faculty], [Department], [Division], [Institution/Organization], [City], [Province/State], [Country].
[Description].	
Consulting	
		
Hospital	
		
Research	
		
University	
		
University Rank	
		
University Cross Appointment	
		
d)	Honours and Career Awards
Received	
[Start – End Dates]	[Award Name], [Faculty], [University Department], [Division], [Institution/Organization], [City], [Province/State], [Country]. ([Award Type], Specialty: [Specialty]. [Educational Level], [Year/Stage])
Awardee Name: [Student Name].
Role: [Role]
Total Amount: [Total Amount] [Currency]
[Description of Award].	
Nominated	
		
e)	Other Noteworthy Activities
[Start – End Dates]	Type: [Type]. Audience: [Audience]. [City], [Province/State], [Country].
[Description].
Results / Evaluation: [Results/Evaluation]	
f)	Patents and Copyrights
[Date of Issue]	[Title]. [Type], [Status]. (Patent or Copyright ) #: [Patent/Copyright #], [Country], Joint Holder Names: [Joint Holder Names].
[Brief Description].	
g)	Grants, Contracts and Clinical Trials
Funded	
[Start – End Dates]
	[Role]. [Title]. [Funding Source], [Funding Program Name], [Grant and/or Account #]. PI: [Principal Investigator]. Collaborators: [Collaborators]. ([Funding Type]).
Total Amount: [Total Grant Amount] [Currency].
[Description].	
Declined	
		
h)	Salary Support and Other Funding
Personal Salary Support	
[Start – End Dates]
	[Funding Title], Trainee Name: [Student Name], [Funding Source], [City], [Province/State], [Country]. Specialty: [Specialty].
Total Amount: [Total Amount] [Currency].	
Trainee Salary Support	
		
i)	Publications
Journal Articles	
 [Authors]. [Title]. [Rest of Citation]. [Publication Status]. Impact Factor: [Journal Impact Factor]. [Trainee Publication]. [Trainee Details]. [Role].
[Most Significant Publication]. [Most Significant Publication Details].	
Case Reports	
	
Abstracts 	
	
Books	
	
Books Edited	
	
Book Chapters	
	
Manuals	
	
Editorials	
	
Monographs	
	
Websites / Videos	
	
j)	Presentations
International	
[Date]	[Role]. [Presentation Type]. [Title]. [Host], [City], [province/State], [Country]. Presenter(s): [Presenters]. [Rest of Citation]. ([Presentation by Trainee])
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
National	
		
Regional / Provincial	
		
Local	
		
k)	Peer Review Activities
Associate or Section Editing	
[Start – End Dates]	[Role]. [Institution/Organization], [Journal/Section], Number of Reviews: [Number of Reviews]	
Editorial Boards	
		
Grant Reviews	
		
Manuscript Reviews	
		
Presentation Reviews	
		
l)	Other Research and Professional Activities
Research Projects	
[Start – End Dates]	[Role].  [Title]. [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor]. Collaborator(s): [Collaborators].	
Thesis Projects	
		
m)	Administrative Service in Education 
[Institution / Organization]	
[Start - End Dates]	 [Role], [Committee Name], [Faculty], [University Department], [Division], [City], [Province / State], [Country]. 
 [Description] 
 Total Hours for Entire Activity: [00] 	
Total number of hours: 	[00]	

XI. Research in Teaching and Education
1)	[Title/Subject of Research Statement]
([Start – End Dates])
Description: [Description].
Impact: [Impact].
Documentation
Note:  Below are samples of all activities that could be attached to a Research in Teaching and Education title.  Include only activities directly related to this Research in Education title.

a)	Degrees
[Start – End Dates]	[Degree], [Subject/Discipline], [Department], [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor].	

b)	Postgraduate, Research and Specialty Training
[Start – End Dates]	[Title/Position], [Subject/Discipline], [Department/Program], [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor].	

c)	Qualifications, Certifications and Licenses
[Start – End Dates]	[Title], [Speciality], [Institution/Organization], [City], [Province/State], [Country], License / Membership #: [License / Membership #].	

d)	Professional Associations
[Start – End Dates]	[Role], [Association Name], [License / Membership #].	

e)	Positions Held and Leadership Experience
Clinical	
[Start – End Dates]	[Title/Position]. [Faculty], [Department], [Division], [Institution/Organization], [City], [Province/State], [Country].
[Description].	
Consulting	
		
Hospital	
		
Research	
		
University	
		
University Rank	
		
University Cross Appointment	

f)	Honours and Career Awards
Received	
[Start – End Dates]	[Award Name], [Faculty], [University Department], [Division], [Institution/Organization], [City], [Province/State], [Country]. ([Award Type], Specialty: [Specialty]. [Educational Level], [Year/Stage])
Awardee Name: [Student Name].
Role: [Role]
Total Amount: [Total Amount] [Currency]
[Description of Award].	
Nominated	

g)	Other Noteworthy Activities
[Start – End Dates]	Type: [Type]. Audience: [Audience]. [City], [Province/State], [Country].
[Description].
Results / Evaluation: [Results/Evaluation]	

h)	Patents and Copyrights
[Date of Issue]	[Title]. [Type], [Status]. (Patent or Copyright) #: [Patent/Copyright #], [Country], Joint Holder Names: [Joint Holder Names].
[Brief Description].	

i)	Grants, Contracts and Clinical Trials
Funded	
[Start – End Dates]
	[Role]. [Title]. [Funding Source], [Funding Program Name], [Grant and/or Account #]. PI: [Principal Investigator]. Collaborators: [Collaborators]. ([Funding Type]).
Total Amount: [Total Grant Amount] [Currency].
[Description].	
Declined	

j)	Salary Support and Other Funding
Personal Salary Support	
[Start – End Dates]
	[Funding Title], Trainee Name: [Student Name], [Funding Source], [City], [Province/State], [Country]. Specialty: [Specialty].
Total Amount: [Total Amount] [Currency].	
Trainee Salary Support	

k)	Publications
Journal Articles	
[Authors]. [Title]. [Rest of Citation]. [Publication Status]. Impact Factor: [Journal Impact Factor]. [Trainee Publication]. [Trainee Details]. [Role].
[Most Significant Publication]. [Most Significant Publication Details].	
Case Reports	
	
Abstracts 	
	
Books	
	
Books Edited	
	
Book Chapters	
	
Manuals	
	
Editorials	
	
Monographs	
	
Websites / Videos	

l)	Presentations
International	
[Date]	[Role]. [Presentation Type]. [Title]. [Host], [City], [province/State], [Country]. Presenter(s): [Presenters]. [Rest of Citation]. ([Presentation by Trainee])
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	
National	
		
Regional / Provincial	
		
Local	

m)	Peer Review Activities
Associate or Section Editing	
[Start – End Dates]	[Role]. [Institution/Organization], [Journal/Section], Number of Reviews: [Number of Reviews]	
Editorial Boards	
		
Grant Reviews	
		
Manuscript Reviews	
		
Presentation Reviews	

n)	Other Research and Professional Activities
Research Projects	
[Start – End Dates]	[Role]. [Title]. [Institution/Organization], [City], [Province/State], [Country]. Supervisor(s): [Supervisor]. Collaborator(s): [Collaborators].	
Thesis Projects	

o)	Teaching
[Activity Type]	
[Start – End Dates]	[Activity Title], [Educational Level], [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
[Activity Description].
Total Hours: [Total Hours]
Number of Students: [Number of Students]
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	

p)	Clinical Supervision
[Educational Level]	
[Start – End Dates]	[Type of Supervision] Supervision. [Role]. [Year/Stage], [Faculty], [University Department], [Division]. Location of Teaching: [Location of Teaching].
[Activity Description].
Student Name(s): [Student Names (Optional)]
Number of Students: [Number of Students]
Unit: [No. of Units] X [Type of Units]
Total Hours: [Total Hours]
Teaching Evaluation Score: [Teaching Evaluation Score]
Evaluation Details: [Evaluation Details]	

q)	Research Supervision
[Educational Level]	
[Start – End Dates]	[Role], [Faculty], [University Department], [Division].
Student Details: [Student Name], Student's Current Position: [Student Current Position], Student's Current Institution: [Student’s Current Institution] 
Degree: [Year/Stage], [Degree/Program of Study]
Research Project: [Research Project Title]
Awards: [Student’s Awards Attained]
Collaborators: [Collaborators]
Completed: [Year Completed]
[Description]	

r)	Mentorship
[Educational Level]	
[Start – End Dates]	[Type of Mentee / Preceptorship], [Mentee Name], [Institution of Mentee], [Mentee Title / Position], [Year/Stage].
[Faculty], [University Department], [Division]. ([Formal], No. of Encounters per Year: [No. of Encounters per Year], Total Hours: [Total Hours])
[Mentor Purpose / Responsibilities}.	

s)	Innovations and Development in Teaching and Education
[Primary Audience]	
[Start – End Dates]	[Title]. 
[Faculty], [University Department], [Division], [Institution/Organization]. 
 [Description]. 
 [Impact]. 
Total Hours: [Total Hours]	

t)	Aggregate Teaching Evaluations
[Educational Level]	
[Start – End Dates]	[Source]. [Faculty], [University Department], [Division].
Teaching Evaluation Score (Individual Mean): [Teaching Effectiveness Score (Individual Mean)]
City Wide Mean: [City Wide Mean]
Hospital Mean: [Hospital Mean]
Division Mean: [Division Mean]
Quintile: [Quintile]
Evaluation Details: [Student Comments]	

u)	Administrative Activities
[Institution / Organization]	
[Start - End Dates]	 [Role], [Committee Name], [Faculty], [University Department], [Division], [City], [Province / State], [Country]. 
 [Description] 
 Total Hours for Entire Activity: [00] 	
Total number of hours: 	[00]	
Other Documentation 
[Other Documentation]

XII. Creative Professional Activities in Teaching and Education
1)	Professional Innovation and Creative Excellence

a)	[Title] 
([Start – End Dates])
Description: [Description].
Impact: [Impact].
Documentation

Table level details are same as for Research in Teaching and Education section of this report.
2)	Contributions to the Development of Professional Practices
Same as for 1) Professional Innovation and Creative Excellence

3)	Exemplary Professional Practice
Same as for 1) Professional Innovation and Creative Excellence