Mini-Fellowship Programs at the
University of Virginia School of Medicine
Certified for AMA PRA Category 1 Credit™.
Overview: The University of Virginia School of Medicine provides opportunities for practicing physicians to pursue clinical observation learning experiences that foster the transfer of new knowledge and skills into practice settings through peer-to-peer discussions, case discussions and clinical observation. This experience is designed to create unique learning opportunities based on identified professional practice gaps and identified goals for improved healthcare delivery to patients. A physician preceptor from the UVA faculty further clarifies the parameters of the clinical observation experience that ultimately provide the foundation for this clinically based experience.
The University of Virginia Office of Continuing Medical Education serves as the certifying sponsor for provision of AMA PRA Category 1 Credit™. In addition, there are specific credentialing requirements for physicians and healthcare professionals who participate in observational experiences that require documentation. These documents include a current professional license in the US, a copy of successful HIPAA course completion and any other documents required by the Credentialing Office.
The attached application serves as a learning contract and provides the foundation for the development of the clinical observational experience. Applicants are asked to complete the application and define the proposed learning goals so that appropriate educational interactions and activities can be planned.
The costs for this experience are based on the proposed length of the clinically based experience. Costs will be identified at the time of approval of the requested observational mini-fellowship. Payment can be made by credit card, or check.
P.O. Box 800711 · Charlottesville, VA 22908-0711
434-924-5310 · Fax: 434-982-1415
APPLICATION FOR MINI-FELLOWSHIP CLINICAL OBSERVATION PROGRAM
Please complete this form online and then print it out and sign it or email it directly to
First Name: M.I. Last Name:
Credentials (MD, PhD, DO etc): Specialty:
Affiliation/Business/Organization
Primary Address: This is __ home ___work
Street
City: State/Province: Postal Code
Country:
Phone: FAX: email
Birthdate: (required for tracking CME credits) MM/DD/YYYY
Do you require any special assistance (physical limitations)? ___ No ___ Yes
If so, please describe______
Which UVA Physician Preceptor(s) have you contacted and arranged a mini-fellowship?
Name: Contact email:
What is the specific area of interest for your Mini-fellowship?
What do want to gain from this experience (your personal learning goals)?
Describe your plans, to utilize/implement this information into your practice? Will it address any specific issues in your current practice?
Please identify the amount of time you would like to participate in this Mini-fellowship?
___ One day
___ Two days
_ _ One week
___ other
YOUR Current Practice setting (check one)
___ academic
___ private practice with academic affiliation
___ private practice with community/regional hospital affiliation
___ community practice with academic affiliation
___ community practice with community/regional hospital affiliation
Please identify the top 5 most common diagnoses for patients in your practice-
1)
2)
3)
4)
5)
Date submitted:
Signature:
P.O. Box 800711 · Charlottesville, VA 22908-0711
434-924-5310 · Fax: 434-982-1415