UTHSC-HRenewal Application

forTMBApproved Fellowship

(Part 2)

Fellowship Name/Program #:

Section 1: Program Information Details

Detail the arrangements for funding of the resident stipend(s) and benefits and specifically identify those facilities that will be providing such support. Note whether the support will be in addition to current funding or if it will reduce positions in current programs.Attach copies of funding commitment letters.

Program Director Information

Name of Program Director:
Title of Program Director:
Faculty appointment date:
Program Director appointment date:
TMB license number: / Expiration:
Board certification: / Date:
Other certification: / Date:
Name of Associate Program Director (if applicable):
Title of Associate Program Director:

Program Coordinator Information

Name of Program Coordinator:
Contact information:

Teaching Faculty Information

Name / Title / Board Certification / Appropriate Educational Qualifications
Add extra lines as needed.

UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011Page 1

Section 2: Applicant and Graduate Fellow Details

Number of applications and number of positions offered for the past five years:

Year / Applications Received / Applicants Interviewed / Positions Offered

List fellows who have entered and completed the program since original approval (up to 5 years), describing their current professional practice and how they are using the training received during this fellowship.

Name / Month/Year Starting Program / Prior GME Training
(Institution)* / IMG
(Yes/No) / Month/Year Completed Program / Application of this Fellowship in Current Practice

*List name(s) of institution(s) where prior GME Training was received.

List the scholarly activity of most recent graduates:

Section 3: Duty Hour Policy

Describe the Duty Hour expectations of the program:

Do fellows take pager call from home? If so, describe the frequency and the typical volume of pages per night.

Do fellows take in-house overnight call? If so, describe the frequency and how Duty Hour limits are maintained.

UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011Page 1

Fellowship Name/Program #:

Section 4: Attachments

If the documents requested are in the program manual, it is not necessary to duplicate the documents in the attachment section. Please indicate the page number where this information may be found in the manual.

Attachment Checklist

/ Attached to this document / This document is not available or not applicable
  1. Funding commitment letters

  1. Program Director CV

  1. Competency-based Goals & Objectives by Rotation

  1. Block Schedule

  1. Evaluation Forms

  1. Program Duty Hour Policy

  1. Program requirements from oversight agency (non-ACGME programs)

Section 5: Department Approvals

Program Director: ______

Date

DMO: ______

Date

Division Head: ______

Date

Chairman: ______

Date

Section 6: GMEC Approvals

Recommendation /

Status

Internal Review (approximate date)
Approval / Date / Comments
IREC
GMEC
Oversight agency (as applicable):
  • TMB

  • Other:

Section 7: Attachment Examples (if applicable)

All electronic files of the attachments should be clearly labeled with the corresponding attachment number 1-7 at the beginning of the file name. (ie. 3-GO-MHH.*; 4-blocksched.*)

  1. Funding commitment letters
  1. Program Director CV
  1. Competency-based Goals & Objectives by Rotation
  • Educational objectives should be constructed to show
  • what the learner is to be able demonstrate at the conclusion of the learning exercise,
  • under what conditions the learner should be able to demonstrate same, and
  • what criteria will be used to judge that performance.
  • Additionally, the each objective should state necessary pre-requisites and they should be appropriately sequenced.
  • An important part of writing appropriate objectives is the use of ‘action verbs’. “Understand” does not meet the criteria for an appropriate objective.
  1. Block Schedule

Three block schedule templates have been provided below. Please use one of these formats.

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12

Rotation

Location

2 months / 2 months / 2 months / 2 months / 2 months / 2 months

Rotation

Location

3 months / 3 months / 3 months / 3 months

Rotation

Location

  1. Evaluation Forms

Attach evaluation forms for:

  • Evaluation of Fellow by Faculty/Program Director
  • Evaluation of Program by Fellow
  • Evaluation of Faculty/Program Director by Fellow
  • Any additional evaluation forms
  1. Program Duty Hour Policy
  1. Program requirements from oversight agency (non-ACGME programs)

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