program requirements pediatric hematology-oncology, iii
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- 1. PEDIATRIC HEMATOLOGY-ONCOLOGY 3/04 RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N. State St., Suite 2000 Chicago, IL 60610 INSTRUCTIONS FOR COMPLETING PROGRAM INFORMATION FORMS FOR PROGRAMS IN Pediatric HEMATOLOGY-ONCOLOGY The same program information form (PIF) is used for those making initial application and those undergoing periodic re-review. This program information form is to be used in conjunction with the Program Requirements for Residency Education in Pediatric Hematology-Oncology. Applications: The RRC will evaluate an application for a new program without a prior site visit. Contact the RRC office for deadlines. Note that a subspecialty program must function in conjunction with a fully accredited program in pediatrics that is in good standing. Title: The title of a subspecialty program should correspond to the title of the affiliated pediatrics program to facilitate cross-referencing. The official name of the core program and ID number may be obtained from the institution or from the director of the core pediatrics program. Refer to the Program Requirements in the Subspecialties of Pediatrics II.A Sponsor: Identify as the SPONSORING INSTITUTION that entity which has final administrative responsibility for the program, as evidenced by the fact that it monitors the quality of the education and coordinates the accreditation activity. This must be the same sponsor as for the core pediatrics residency. If the SPONSORING INSTITUTION and the PRIMARY HOSPITAL are one and the same, the hospital's name should be entered in both sections. Before work is begun on this form, the Program Requirements for Subspecialties of Pediatrics and the Program Requirements for Residency Education in Pediatric Hematology-Oncology should be thoroughly reviewed. Copies of these documents may be obtained from the ACGME website (www.acgme.org). If more than one hospital participates in the program, information on each hospital should be given as requested. The program director is responsible for gathering the requested data from the participating institutions and consolidating the information on one form. The total length of time subspecialty residents are assigned to each participating hospital should be filled in as requested on Pages 1 and 2. It is important that the original pagination remain the same. If necessary, paginate the forms by hand in the upper right corner. See note below. All sections of the form must be completed. If any requested information is not available, an explanation should be given in the appropriate place on the form. The completed form should be prepared as a single document with all added pages numbered in sequence as requested. INCLUDE ONLY THE REQUESTED INFORMATION. INCOMPLETE APPLICATIONS WILL BE RETURNED, WHICH COULD DELAY THE DECISION MAKING PROCESS.
2. -2- The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the Department Chair/Chief of Service and the Designated Institutional Official (DIO) of the sponsoring institution. ALL PAGES INCLUDED IN THE FORM SHOULD BE 8 2" BY 11". DO NOT USE UNDERSIZED OR OVERSIZED SHEETS. Each copy of the completed form may be secured with a rubber band, a clip, or it may be loosely enclosed in protective materials. DO NOT punch holes in the form. Remove all staples within the form, e.g., from the CV's. DO NOT use any kind of process to bind the form or attach it to anything. DO NOT insert section dividers. The number of copies to be submitted will vary as follows: New application: Send four complete copies to the Executive Director of the Residency Review Committee for Pediatrics at the above address. Resurvey: See letter announcing the site visit. Resident: Resident and subspecialty resident are used interchangeably in this document. Pediatric residents are referred to as such. If you have questions about the form, contact the Accreditation Administrator (Phone: 312-755-5044). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For questions regarding a site visit, contact the writer of the letter announcing the survey. NOTE THAT THE DOCUMENT IS SET FOR AUTOMATIC PAGE NUMBERING. IF THIS PRESENTS A PROBLEM, GO TO THE TOP OF THE FIRST NUMBERED PAGE 1, TURN PAGE NUMBERING OFF BY CLICKING ON FORMAT, PAGE, AND THEN NUMBERING. IF YOU TURN THIS FEATURE OFF, HAND NUMBER ALL PAGES SEQUENTIALLY IN ACCORDANCE WITH THE INSTRUCTIONS. Pedspif-pd327pif03.doc 3. THE RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS Pediatric Hematology-Oncology PROGRAM INFORMATION FORM CHECKLIST Use this checklist before submitting the forms to the RRC office. The RRC considers it the responsibility of the program director to ensure that the application materials are complete. The signature of the program director on the forms indicates his/her approval of the content. A review of the instructions provided at the beginning of the form and on individual pages is suggested. Have the appropriate person(s) signed page 1 of the forms where requested? _______ Has Appendix A, the program director=s CV, been attached? _______ Has Appendix B, the one-page CV of each essential faculty member, been included according to the instructions? Is the form free of unrequested schedules, printouts, reprints, catalogs, brochures, etc.? Are all requested official letters of agreement/affiliation appended as requested on pages 1 and 2? Has the final copy been carefully proofread, and has it been checked to see that every question has been answered, every chart completed, etc.? Once the preparer is satisfied that the form has been completed and assembled correctly, make the appropriate number of copies. After the copies have been made, review the individual sets to be sure that all of the copied pages are legible and that each set of forms contains all of the pages in the original. ALL PAGES INCLUDED IN THE FORM SHOULD BE 8-1/2" by 11". DO NOT USE UNDERSIZED OR OVERSIZED SHEETS. The completed copies of the form may be secured with one large rubberband or enclosed in a folder. DO NOT STAPLE INDIVIDUAL SECTIONS. Holes should not be punched in the form and it should not be attached to the folder. DO NOT INCLUDE THIS PAGE IN THE PROGRAM INFORMATION FORMS. 4. 3/04 RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 North State Street, Suite 2000, Chicago, Illinois 60610 PROGRAM INFORMATION FORM PEDIATRIC HEMATOLOGY-ONCOLOGY MEDICINE Date: New Program Application: Yes No TITLE OF PROGRAM: (Use first line of program listing on the ACGME Website for core Pediatrics program to which this program is attached.) 10-digit ACGME Subspecialty Program ID # 327____________ Title of Core Pediatrics Program: 10-digit ACGME Core Pediatrics Program ID# Accreditation Status of Core Pediatrics Program: Name and mailing address of Pediatric Hematology-Oncology Program Director: Name: Full Time: YES NO Title: Address: E-mail Address: Telephone: Fax: The signatures of the director of the program and the chief of the department attest to the completeness and accuracy of the information provided on these forms. Pediatric Hematology-Oncology Program Director Name (typed): Chief of Pediatrics/Department Chair Name (typed): Signature: Signature: Program Requirements for Subspecialties of Pediatrics II.A . SPONSORING INSTITUTION: (Name the entity, i.e., the university, hospital, or foundation that has administrative responsibility for this program. Must be the same as the sponsor of the core pediatrics program.) Name of Sponsor: Address: Name of Designated Institutional Official (DIO) (Typed): Signature: Is there an affiliation with a medical school? If so, name: Yes No 5. Program Requirements for Subspecialties of Pediatrics II.B. 2 PRIMARY HOSPITAL (Hospital 1) Name: Address: Total number of months Pediatric Hematology-Oncology subspecialty resident is assigned to this institution in each year of training: Year 1: Year 2: Year 3: Chief/Chair, Department of Pediatrics: For each participating institution provide letters of agreement specifying the administrative and organizational relationships which bear upon the educational program. Attach as Appendix C. OTHER PARTICIPATING INSTITUTION (Hospital 2) Name: Address: Total number of months Pediatric Hematology-Oncology subspecialty resident is assigned to this institution in each year of training: Year 1: Year 2: Year 3: Distance between 2 and 1 in: Miles: Minutes: Is this hospital used for: (Please X appropriate box) Required rotations? Elective rotations? Both? OTHER PARTICIPATING INSTITUTION (Hospital 3) Name: Address: Total number of months Pediatric Hematology-Oncology subspecialty resident is assigned to this institution in each year of training: Year 1 Year 2 Year 3 Distance between 3 and 1 in: Miles: Minutes: Is this hospital used for: (check appropriate box) Required rotations? Elective rotations? Both? 6. 3 BACKGROUND INFORMATION Provide a response for each of the points below. If a category is not applicable, list it and indicate N/A. 1. PREVIOUS CITATIONS AND/OR CONCERNS: List each of the citations and/or concerns, if any, from the notification letter that was sent following the last survey and review of the program and briefly and concisely describe the steps that have been taken to correct the problem. If such correction is documented in the program information form you prepare for this review, provide page references 2. CHANGES: Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above), that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, program director, essential faculty, resident complement, etc. 7. 4 SUBSPECIALTY RESIDENTS Programs making initial application should provide ONLY THE INFORMATION marked by an asterisk (*) in the top section of the page. Program Requirme