Neuroimaging

PROGRAM ACCREDITATION APPLICATION

PROGRAM INFORMATION FORM (PIF)

FOR NEW APPLICATIONS ONLY

Revised:December 2013

A. INTRODUCTION

The mission of the United Council for Neurologic Subspecialties (UCNS) is to provide an accreditation process for fellowship training programs with the goals of enhancing quality training in neurologic subspecialties and quality patient care.The Accreditation Council strives to develop evaluation methods and processes that are valid, effective, fair, open, and ethical.The Accreditation Council is a voluntary accreditation organization and functions as a Council of the UCNS.To be an accredited program by the UCNS, compliance with the program requirements is monitored through completion of the Program Information Form(PIF). In creating this form, the Accreditation Council has referenced the model used by the Accreditation Council for Graduate Medical Education (ACGME).

B. INSTRUCTIONS

APPLICATION FOR NEW PROGRAM: This form is for use by programs submitting an initial application for provisional accreditation only.

All programsmust complete the entire Program Information Form.Many items require a composed response to a specific question. Please respond briefly and concisely.Do not attach any unnecessary materials such as reprints, brochures, annual reports, schedules (unless otherwise requested), minutes of meetings and conferences, etc. UCNS considers ONLY the information REQUESTED in the PIF and in the appendices. Any extra material will be discarded. All forms and templates that are provided MUSTbe used. Failure to comply with the rules stated above will delay the review process and may result in the denial of the program’s application for accreditation.

For new training programs where statistical data is not available, e.g., the number of graduates, you should mark that section as “NA” (not applicable).Processes and curricula projected for a program should be described in present tense, as though already in operation. Programs must demonstrate that processes for the education, evaluation, etc. of fellows are in place.

The PIF and Appendix A-Jtemplatesmust be downloaded and completed off-line. The PIF question fields may not be altered.The space in text and tables for responses will expand to accommodate your program’s needs.The page numbers will automatically reformat.Should you require additional rows in specific tables, please e-mail UCNS.Once the PIF and Appendices A-Jare completed, submit them as Word documents via e-mail to UCNS at will send a confirmation acknowledging receipt of the application.

The program director is responsible for the content of the completed form, and the information will not be considered complete without all required signatures and the appropriate payment.All sections of the form applicable to the program must be completed in order to be accepted for review.If any requested information is not available, an explanation mustbe given in the appropriate place on the form.

Appendix A:Institution letter(s) [template provided]

Appendix B:Curricula vitae (program director and all faculty)[template provided] NIH biosketches and complete curricula vitae are NOT accepted

Appendix C: Graphic display of the curriculum [template provided]

Appendix D:Program rotation goals and objectives [template provided]

Appendix E:Formal didactics[template provided]

Appendix F:Clinical components [template provided]

Appendix G:Duty hours compliance

Appendix H:Fellow meeting attendance, research projects, publications, and scholarly activity[template provided]

Appendix I:Evaluation form samples

Appendix J:Neuroimagingspecific

C. APPLICATION FEE

You are applying for program accreditation as a New Applicant.

New Applicant$2,000 non-refundable application fee

The accreditation year is the academic year, July 1 through June 30. An annual accreditation fee will be assessed at $1,500 for all accredited programs. Fees are subject to change.

D. PAYMENT

UCNS accepts checks (or money orders) only at this time.Credit cards and electronic fund transfers are not accepted. Please submit payment in US funds (payable to United Council for Neurologic Subspecialties) to UCNS, 201 Chicago Avenue, Minneapolis, MN 55415.

E. APPLICATION DEADLINE

UCNS accepts applications throughout the year and reviews applications twice per year, in the spring and fall. Your application must be submitted and payment received by December 1 for spring review and June 1 for fall review.

F. QUESTIONS

Contact UCNS with questions:UCNS, 201 Chicago Avenue, Minneapolis, MN 55415 Tel: 612-928-6399 Fax: 612-454-2750. E-mail: .

G. GLOSSARY OF TERMS

A glossary of terms used in the program requirements and PIF can be found on the UCNS website at

TABLE OF CONTENTS

Section / Page
1 / Program Information
1.A / Program Identification
1.B / Program Director Information
2 / Institutional Affiliates
2.A / Sponsoring Institution
2.B / Primary Institution
2.C-F / Participating Institution
2.G / Overseeing Department
3 / Fellow Information
3.A / Number of Positions
3.B / Actively Enrolled Fellows
3.C / Aggregate Data on Fellows Completing or Leaving the Program for the Last Three Years
3.D / Fellows Completing the Program in the Last Three Years
4 / Faculty and Personnel
4.A / Program Director
4.B / Core Faculty
4.C / Other Faculty
5 / Facilities and Resources
5.A / Facilities and Resources
6 / Educational Program
6.A / Curriculum
6.B / Seminars and Conferences
6.C / Educational Program
6.D / Program Policies
7 / Research and Scholarly Activity
8 / Evaluation
8.A / Fellow Evaluation
8.B / Faculty Evaluation
8.C / Program Evaluation
8.D / Curriculum Development
8.E / Curriculum Evaluation
9 / Signatures
Appendices
A / Institution Letter(s)
B / Curriculum Vitae
C / Graphic Display of the Curriculum
D / Goals and Objectives
E / Formal Didactics
F / Clinical Components
G / Duty Hours Compliance
H / Fellow Meeting Attendance, Research Projects, Publications, and Scholarly Activity
I / Evaluation Form Samples
J / Neuroimaging specific

PROGRAM INFORMATION FORM (PIF)

SECTION 1.PROGRAM INFORMATION

A.Program Identification

Date:
Name of primary institution:
Title of program:
Does your program currently have fellows? Yes No
If yes, how many fellows do you have each year?
How many years is the fellowship?
UCNS program number(for office use only):

B.Program Director Information

Name: / Credentials (MD, MPH, etc.):
Title:
Address:
City / State: / Zip code:
Telephone: / FAX: / Email:
Date the programdirector was first appointed:
Primary specialty board certification: / Most recent certification/recertificationdate:
Secondary specialty board certification: / Most recent certification/recertificationdate:
Is the program director ABMS or RCPSC (i.e., ABPN, ABIM) certified? / YES / NO
Is the program director UCNS certified in Neuroimaging? / YES / NO
Number of years spent teaching in GME in this subspecialty:
Is the program director a full-time staff member of the sponsoringor primaryinstitution? / YES / NO
Does the program director hold a current license to practice medicine in the state of the sponsoring or primaryinstitution? / YES / NO
Is the program director based at primary teaching institution? / YES / NO
Percentage of hours per week the program director spends in:
Clinical (Time spent in patient care): / Administration (Time spent in program administrative duties): / Research (Time spent completing research activities): / Education (Time spent instructing fellows and preparing instruction materials):
Is the program director also the department chair? / YES / NO
If no, chair name and credentials:

SECTION 2. INSTITUTIONAL AFFILIATES(Program Requirements II.)

Instructions: Complete the tables below for all institutions associated with the program. Institution definitions are listed in the program requirements. Using the template provided for Appendix A, submit an institutional letter for each sponsoring, primary, and participating institution listed below.

  1. SPONSORING INSTITUTION: (Institution #1) (The university, hospital, or foundation that has ultimate responsibility for this program and must be accredited as a sponsoring institution by the ACGME.)

Name of sponsor:
Address:
City: / State: / Zip code:
Type of institution: (e.g., teaching hospital, general hospital, medical school):
Ownership type: (e.g., state, corporation, church):
Is the institution ACGME accredited YES NO / Duration of accreditation: / Next review date:
Name and credentials of the designated institutional official:
Does theSPONSOR have an affiliation with a medical school (may be the sponsoring institution)? / YES / NO
If yes, name of medical school:
  1. PRIMARY INSTITUTION (Institution #2)

Same as the sponsoring institution

Name:
Address:
City: / State: / Zip code:
Name and credentials of theindividual responsible for oversight of training at this institution:
  1. PARTICIPATING INSTITUTION (Institution #3)

Not applicable

Name:
Address:
City: / State: / Zip code:
Distance from primary institution / Miles: / Minutes:
Type of rotation (select one) / Elective / Required / Both
Duration of fellow’s rotation (in months) / Year 1: / Year 2:
Name and credentials of theindividual responsible for oversight of training at this institution:
Brief educational rationale for use of this institution:
  1. PARTICIPATING INSTITUTION (Institution #4)

Not applicable

Name:
Address:
City: / State: / Zip code:
Distance from primary institution / Miles: / Minutes:
Type of rotation (select one) / Elective / Required / Both
Length of fellows rotation (in months) / Year 1: / Year 2:
Name and credentials of the individual responsible for oversight of training at this institution:
Brief educational rationale for use of this institution:
  1. PARTICIPATING INSTITUTION (Institution #5)

Not applicable

Name:
Address:
City: / State: / Zip code:
Distance from primary institution / Miles: / Minutes:
Type of rotation (select one) / Elective / Required / Both
Length of fellows rotation (in months) / Year 1: / Year 2:
Name and credentials of the individual responsible for oversight of training at this institution:
Brief educational rationale for use of this institution:
  1. PARTICIPATING INSTITUTION (Institution #6)

Not applicable

Name:
Address:
City: / State: / Zip code:
Distance from primary institution / Miles: / Minutes:
Type of rotation (select one) / Elective / Required / Both
Length of fellows rotation (in months) / Year 1: / Year 2:
Name and credentials of the individual responsible for oversight of training at this institution:
Brief educational rationale for use of this institution:
  1. OVERSEEING DEPARTMENT(Previously referred to as “Core Program”)

Specialty:
Name of institution or hospital:
Address:
City, State, Zip Code: / State: / Zip code:
Website address:
Date program approved for accreditation:
Next review date:
Name of program director:

SECTION 3.FELLOW INFORMATION

A.Number of Positions (For the current academic year)

Positions / Year 1 / Year 2 / Year 3 / Total
Number of requested positions
Number of filled positions*
*For established programs without currently active fellows, complete table with 0 and indicate here when last enrolled fellow finished. For programs that have never had fellows, complete table with “NA”.

Note: The fellow complement is the number of fellows allowed to be enrolled in the program. There must be at least 1 core faculty members for every 1 fellow. The number of fellows enrolled in the program at any time must not exceed the fellow complement.

B.Actively Enrolled Fellows (if applicable) (Program Requirements V.)

1. List all fellows actively enrolled in this program as of August 31 of the current academic year (see Section 3.A). List names alphabetically. Indicate fellows accepted as transfer with an asterisk (*). If no fellows are currently enrolled, please write “NA” in the table.

YEAR ONE

Name / Medical school / Prior GME trainingprogram / ABMS/RCPSC eligible or certified?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO

YEAR TWO

Not applicable because the program does not offer a second year

Name / Medical school / Prior GME trainingprogram / ABMS/RCPSC eligible or certified?
YES NO
YES NO
YES NO
YES NO
YES NO

YEAR THREE

Not applicable because the program does not offer a third year

Name / Medical school / Prior GME trainingprogram / ABMS/RCPSC eligible or certified?
YES NO
YES NO
YES NO
YES NO
YES NO

2. Are you planning to train non-ACGME or non-RCPSC trained fellows?If yes, be aware that non-UCNS certifiable trainees must be included in the fellow complement. What effect will this have on your faculty resources?

  1. Aggregate Data on Fellows Completing or Leaving the Program for the Last Three Years

Start with the most recent year in the first column.

Not applicable because the program has not graduated any fellows

Based in academic year ending: / June 30, (indicate year) / June 30, (indicate year) / June 30, (indicate year)
Number of graduates
Number of fellows who withdrew from the program*
Number of fellows who transferred out of the program*
Number of fellows on leave of absence from the program*
Number of fellows dismissed from the program*

*Please provide reason(s) for fellows who left the program in the last three years (e.g., withdrawn, transferred, leave of absence, or dismissed).

  1. Fellows Completing Program in the Last Three Years

Beginning with the most recent graduated cohort, list all fellows who have completed all training for this subspecialty based on the last academic year ending June 30,.

Not applicable because the program has not graduated any fellows

Name / Start date / Actual date of completion / Practice position / ABMS certified? / UCNS certified?
YES NO / YES NO
YES NO / YES NO
YES NO / YES NO

List fellows who have completed all training for this subspecialty based on the academic year ending June 30,.

Not applicable because the program has not graduated any fellows

Name / Start Date / Actual Date of Completion / Practice Position / ABMS Certified? / UCNS Certified?
YES NO / YES NO
YES NO / YES NO
YES NO / YES NO

List fellows who have completed all training for this subspecialty based on the academic year ending June 30,.

Not applicable because the program has not graduated any fellows

Name / Start date / Actual date of completion / Practice position / ABMS certified? / UCNS certified?
YES NO / YES NO
YES NO / YES NO
YES NO / YES NO

SECTION 4.FACULTY AND PERSONNEL

A.Program Director(Program Requirements IV.)

1.Describe the program director’s qualifications in Neuroimaging. Indicate appropriate qualifications, including clinical, educational, and administrative abilities, as well as experience in his/her field.

2. List the program director’s educational experience and abilities. Examples should be submitted documenting the program director’s prior and ongoing experience in teaching, lecturing, or writing on topics related to Neuroimaging, as well as experience in administration of educational programs.

3.Listthe program director’s CME activities related to Neuroimaging in the past three years

4.Brieflydescribe the program director’s overall responsibilitiesand activities ensuring that all responsibilities of the program director that are listed in the program requirements are addressed.

B. Core Faculty – Neuroimaging(Program Requirements IV.)

Core faculty are physicians who oversee clinical training in the subspecialty. The program director is considered a core faculty member for the purpose of determining the fellow complement.Beginning with the program director, list all members of the program responsible for training.Include all core faculty. See Section 2 for institution numbers.

Name / Credentials (MD, MPH, etc.) / Institutional privileges / Neuroimaging Certification
UCNS Certified
UCNS Eligible
Role in Curriculum: Program Director
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:

Using the template provided for Appendix B, attach a curriculum vitae for each of the faculty listed above. CVs submitted in a format other than that of Appendix B will not be accepted. A CV must be submitted for eachperson includedabove.

If additional rows are needed to list more than 11 faculty, please e-mail .

C.Other Faculty

Other faculty are physicians and other professionals determined by the subspecialty to be necessary in order to deliver the program curriculum. See Section 2 for institution numbers.

Name / Credentials (MD, MPH, etc.) / Institutional privileges / Neuroimaging certification
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:
UCNS Certified
UCNS Eligible
Role in Curriculum:

Using the template provided for Appendix B, attach a curriculum vitae for each of the faculty listed above. CVs submitted in a format other than that of Appendix B will not be accepted. A CV must be submitted for eachperson includedabove.

If additional rows are needed to list more than 11faculty, please e-mail .

SECTION 5. FACILITIES AND RESOURCES (Program Requirements III.)

A.Facilities and Resources

1.Indicate in the table below the availability of the program’s facilities and resources.

Facilities and Resources / Present
a.Is there administrative support for the fellowship and program director? / YES NO
b. Fellow offices and resources
Do fellows have space to complete administrative responsibilities? / YES NO
Is there administrative support for fellows? / YES NO
Does the fellow have access to office equipment such as copiers, slide projectors, PowerPoint, video projector equipment, or technology services for slide presentations, illustration services? / YES NO
c. Do fellows and faculty have access to reference materials such as textbooks, journals, and online databases? / YES NO

2.Briefly describe the facilities that will be used for conferences.

UCNS Program Accreditation Application Page 1 of 19

Neuroimaging©2013

SECTION 6. EDUCATIONAL PROGRAM

A. Curriculum

  1. Please provide a narrative overview of this training program.Include a discussion of strengths and challenges.
  1. Using the template provided for Appendix C, describe in block form the typical curriculum for fellows by months (or four-week stints), not weeks, including the institution (#1, 2, 3, 4) as listed in Section 2.

Curricular components may be offered in blocks or longitudinally.An example of the latter is a regularly scheduled clinic attended over a period of time while assigned to other rotations.Those components offered in block assignments each year should be recorded in the appropriate block template, if applicable. Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. Conferences, lectures, or other didactic experiences must not be included in the longitudinal template. If the program does not utilize block assignments you may submit a description applicable to your program; however, programs that do use the provided template may encounter delays in review if the reviewers require further clarification.