Invited Faculty Payment Request

Please note: All fields marked with a*are required. All other fields are optional.

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Submitter Name*

Email Address*

Guest Faculty Name*

Guest Faculty Email*

Guest Faculty Phone

Block/Course*

Date(s)/Time of teaching activities *Please enter any other interests not listed above and/or any additional comments

Type of teaching activity

Lecture $175/hour

Lab $75/hour

# of teaching hours

Title of Teaching Session(s)*

Justification*

Curriculum Development/Consulting*

Budget area

Medical Education

Research

Total Amount Requested*

Block/Course Director Name*