CONSORTIUM DATA FORM

  1. Institutions Comprising the Consortium
  1. Name ______

City, State ______

CEO or Comparable Official ______

Telephone ( ) ______

Accredited by: ______

Check appropriate category:

□ Public□ Private, Not for Profit□ Private, for Profit

B.Name ______

City, State ______

CEO or Comparable Official ______

Telephone ( ) ______

Accredited by: ______

Check appropriate category:

□ Public□ Private, Not for Profit□ Private, for Profit

C.Name: ______

City, State ______

CEO or Comparable Official ______

Telephone ( ) ______

Accredited by: ______

Check appropriate category:

□ Public□ Private, Not for Profit□ Private, for Profit

  1. Chief Administrative Officer of Consortium

Name & Credentials ______

Title ______

Address ______

Telephone ( ) ______

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faculty / Personnel responsibilities Form

Instructions: This chart is intended to provide an overview of the distribution of program related activities among key personnel. List key professional and clerical personnel of the program. For each individual, record the approximate percentage of employee’s time dedicated to the program and check off pertinent responsibilities.

Program Personnel

/ Administrative / Curriculum Development / Coordination of Instruction / Teaching / Student Performance Evaluation / Faculty Coordination / Student Recruitment / Student Selection / Administrative Assistance / Secretarial/ Clerical / Other
(please specify)
Name / Title / %
Of Time Dedicated To Program

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PROGRAM DIRECTOR VITAE SUMMARY FORM

(If the Medical Director or Education Coordinator also serves as Program Director, only one form needs to be filled out. Please indicate dual role.)

-Please limit this summary to one (1) page

-USE THIS FORM ONLY – DO NOT SUBMIT COMPLETE VITAE

-Refer to Standards and Guidelines III.B.1.a. & b.

NAME: (Last, first, middle initial)TITLE

EDUCATION: (Begin with baccalaureate or other initial professional education and include postdoctoral)

INSTITUTION & LOCATIONDEGREEYEAR CONFERREDFIELD

CERTIFICATIONSAGENCYYEAR OBTAINED

HONORS

PROFESSIONAL EXPERIENCE: (List employment in reverse chronological order)

EXPERIENCE IN EDUCATION: [note: This can be demonstrated in many ways. See Guideline III.B.1.b.]

CONTINUING EDUCATION: (Last two years only)

RESEARCH / PUBLICATIONS: (List in reverse chronological order; please include only the most recent 5 items or those that pertain to cytopathology)

MEDICAL DIRECTOR VITAE SUMMARY FORM

-Please limit this summary to one (1) page

-USE THIS FORM ONLY – DO NOT SUBMIT COMPLETE VITAE

--Refer to Standards and Guidelines III.B.2.a. & b.

NAME: (Last, first, middle initial)TITLE

EDUCATION: (Begin with baccalaureate or other initial professional education and include postdoctoral)

INSTITUTION & LOCATIONDEGREEYEAR CONFERREDFIELD

CERTIFICATIONSAGENCYYEAR OBTAINED

HONORS

PROFESSIONAL EXPERIENCE: (List employment in reverse chronological order)

EXPERIENCE IN EDUCATION: [note: This can be demonstrated in many ways. See Guideline III.2.b.]

CONTINUING EDUCATION: (Last two years only)

RESEARCH / PUBLICATIONS: (List in reverse chronological order, include only the most recent 5 items or those that pertain to cytopathology)

EDUCATION COORDINATOR VITAE SUMMARY FORM

-Please limit this summary to one (1) page

-USE THIS FORM ONLY – DO NOT SUBMIT COMPLETE VITAE

-Refer to Standards and Guidelines III.B.3.a. & b.

NAME: (Last, first, middle initial)TITLE

EDUCATION: (Begin with baccalaureate or other initial professional education and include postdoctoral)

INSTITUTION & LOCATIONDEGREEYEAR CONFERREDFIELD

CERTIFICATIONSAGENCYYEAR OBTAINED

HONORS

PROFESSIONAL EXPERIENCE: (List employment in reverse chronological order)

EXPERIENCE IN EDUCATION: [note: This can be demonstrated in many ways. See Guideline III.B.3.b.]

CONTINUING EDUCATION: (Last two years only)

RESEARCH / PUBLICATIONS: (List in reverse chronological order; include only the most recent 5 items or those that pertain to cytopathology)

FACULTY &/or INSTRUCTIONAL STAFF VITAE SUMMARY FORM

(This includes medical and cytotechnologist personnel involved in training cytotechnology students)

-Please limit this summary to one (1) page

-USE THIS FORM ONLY – DO NOT SUBMIT COMPLETE VITAE

-Refer to Standards and Guidelines III.B.4.a. & b.

NAME: (Last, first, middle initial)TITLE

EDUCATION: (Begin with baccalaureate or other initial professional education and include postdoctoral)

INSTITUTION & LOCATIONDEGREEYEAR CONFERREDFIELD

CERTIFICATIONSAGENCYYEAR OBTAINED

HONORS

PROFESSIONAL EXPERIENCE: (List employment in reverse chronological order)

CONTINUING EDUCATION: (Last two years only)

RESEARCH / PUBLICATIONS: (List in reverse chronological order; include only the most recent 5 items or those that pertain to cytopathology)

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COMPETENCY & COURSE SEQUENCING FORM

INSTRUCTIONS: This form is intended to present a synopsis of where in the curriculum entry-level competencies are met as well as the sequence of courses and program activities.

For each course of the program, please check the appropriate entry-level competency(ies) that are met for that course. In addition, indicate the year in which that course is taught and present a schematic representation of when and in what sequence each course is taught by shading in the horizontal spaces as appropriate.

For those programs that are considered as 4-year programs of study, please exclude those courses that are required before entry into the professional curriculum track. For a majority of allied health programs, there will be entries for only one or two years.

COURSES
(please list) / COMPETENCIES ( appropriate box) / YEAR
T
A
U
G
H
T / Program Month
(shade boxes when taught)
GYN Screening & Interpretation / NON-GYN Screening & Interpretation / Basic Laboratory Techniques / Laboratory Operations / Ancillary Testing & New Technologies / Scientific Method of Inquiry / Professional Development / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12

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PROGRAM BUDGET

DESCRIPTION / PAST
YEAR _____ / CURRENT
YEAR _____ / PROJECTED
YEAR _____
SALARIES & WAGES
Faculty (FT)
Faculty (PT)
Staff (FT)
All other salaries/
Wages
Fringes
INSTRUCTIONAL SUPPLIES
Including books, journals, A-V software, minor equipment and instruments
TRAVEL
CAPITAL EXPENDITURES
Including major equipment, building, renovation / ______/ ______/ ______
TOTAL BUDGET

METHODS & FREQUENCY STUDENT EVALUATION FORM

INSTRUCTIONS: Indicate the frequency of each evaluation method for each didactic, clinical course and clinical practicum of the program.

COURSE TITLE / EVALUATION METHOD
(Record frequency)
Written Exam / Practical Exam / Evaluation of Student's Clinical Performance / Project / Other
(please specify evaluation method)

Revised 4/05

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