MCGAWMEDICALCENTER of NORTHWESTERN UNIVERSITY
INITIAL ACCREDITATION APPLICATION FOR Non-Standard Fellowship
Date:
Program Name:
Sponsoring division/department:
Program director:
Contact Address:
Contact Phone:
Contact E-mail:
Program Coordinator or Administrator:
Contact Address:
Contact Phone:
Contact E-mail:
Fellowship Track (please see McGaw Program Directors Website for fellowship track criteria):
NAMF ______ASTP______
Funding source for fellowship; (please attach letter of commitment for appropriate PGY-level stipend and benefits for desired total complement) :
Primary Core Residency Program and name of program director:
Length of training:
____ 1 Year ____2Year ____Other
Describe prerequisite of training requirements. Please specify if completion of an ACGME residency is required:
Is there a national society which sponsors this training?
Desired total fellow complement
(Total number of fellows in training at one time): ______
PGY level at start (example: if three-year residency is a prerequisite, fellow starts at PGY-4):
Do you anticipate the possibility of taking an international medical graduate as a fellow?
____ Yes ____ No
Provide a brief statement of overall goals and objectives of the fellowship training:
Describe any academic/research component to the fellowship:
List any research support/travel support (if applicable):
Outline a detailed plan to avoid clinical competition with other trainees:
Will fellow’s clinical services be billed? If yes, outline in what situations this will occur. Please also specify how this will not impact other trainee’s experience:
Outline any fellow teaching responsibilities:
List any applicable weekly or monthly conferences in which the fellow will participate or present:
Outline the plan for formal evaluations. (This must include at least two evaluative tools):
Outline the plan for formal feedback and mentoring. (This must include at least a semi-annual documented review with the program director):
Outline estimated duty hours if applicable (NAMF) and the plan for tracking:
Please attach a block diagram of training schedule.
List key core faculty:
Signatures:
Program Director:
Name:
Signature:
Chairman or Division Director:
Name:
Signature:
Associate Dean for Hospital Clinical Affairs* or designee:
Name:
Signature:
If there are settings in which there will be educational integration of fellows with current resents and/or fellows in the same specialty/subspecialty, please obtain signatures of the relevant program director(s).
Program Director of ______:
Name:
Signature:
Program Director of ______:
Name:
Signature:
If the fellow will be seeing ambulatory patients in an NMG office on the main campus (e.g., Galter), please obtain Dr. Howard Chrisman’s signature (or designee).
Name:
Signature:
Chair, Graduate Medical Education Sub/Committee NAMF/ASTP:
Name: Joshua Goldstein, M.D.
Signature: