Appendix B: Curriculum Vitae

Neuroimaging

Program Accreditation Application

Appendices A-JTemplates

Please note:

All templates and forms provided within this document must be used.
Only provide requested information.

Appendix A: Institution Letter

The institution letter referenced in the Program Information Form (PIF) Section 2 is a confirmation of participation letter from the appropriate institution official of each sponsoring, primary, and participating institution of your program. Submitted letters must utilize the template language below for Appendix A. Do NOT submit the full affiliation or letter of agreement. The letter must include the signature of the appropriate official.

Institution definitions: 1) the sponsoring institution, which assumes ultimate responsibility for the program and is required of all programs, 2) the primary institution, which is the primary clinical training site and may or may not be the sponsoring institution, and 3) the participating institution, which provides required experience that cannot be obtained at the primary or sponsoring institutions. The sponsoring institution letter must be signed by the ACGME/RCPSC-accredited sponsoring institution’s designated institution official.

The following is the template languagefor the letter:

Date

John Kohring, Executive Director

United Council for Neurologic Subspecialties

201 Chicago Avenue

Minneapolis, MN 55415

Dear Mr. Kohring,

This letter serves as the [Sponsoring/Primary/Participating] Institution Letter that accompanies the accreditation application for the [Program Name].

The [institution name] is committed to the training and committed to providing the appropriate education.[List specific educational activities that will be undertaken, supported, and supervised at the institution].

Sincerely,

[Name]

[Designated Institution Official/Department Chair/Medical Director]

[Institution Name]

Appendix B: Curriculum Vitae (CV)

Use the CV template provided below for Appendix B for the entire program faculty. This must include the program director and all faculty listed in the faculty tables in PIF Section 4. CVs MUST be submitted using this template. NIH biosketches and complete CVs will not be accepted.

CURRICULUM VITAE

Name: / Credentials:
Degree(s): / Title:
Medical School: / Date of Graduation:
Residency: / Date of Graduation:
Fellowship: / Date of Graduation:
Certification(s):
ABPN/RCPSC-Neurology / YES NO / Date:
ABPN/RCPSC-Child Neurology / YES NO / Date:
ABMS/RCPSC-Other (specify): / YES NO / Date:
UCNS (specify): / YES NO / Date:
Other (specify): / YES NO / Date:
List any equivalent training here: / Date:
Active state licensure(s): / Date(s):
Current academic positions: / Date assumed this position:
Current hospital appointments: / Date of appointments:
Full time
Part time / If part time:
How many weeks per year: How many hours per week:

Describe any teaching/curricular experience. Also include any administrative experience/appointments, including the location and dates of appointment.

List the most recent publications in journals (maximum 10 articles). Do not include presentations, abstracts, and those ‘in preparation’ or ‘submitted.’

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Appendix C: Graphic Display of the Curriculum

Using ONE of the three templates provided below for Appendix C, describe the typical curriculum for fellows. If more than one curricular option is offered, please copy the template and include all options available within the program, ensuring that each option is clearly identified.

Option 1 – Block Rotations in Months

Using the template provided below for Appendix C, describe in block form the typical curriculum for fellows by months including the institution (#1, 2, 3, 4) as listed in PIF Section 2. If you require an extended table, please e-mail your request to .

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 block template. Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. You should not include conferences, lectures, or other didactic experiences in the longitudinal template.

Year 1

BLOCK ROTATIONS

July / August / September / October / November / December / January / February / March / April / May / June

LONGITUDINAL EXPERIENCES

Type of experience / Time commitment per week / Number of weeks per year / Amount of time in months (e.g., 40 half days=1 month)

Year 2

Not applicable

BLOCK ROTATIONS

July / August / September / October / November / December / January / February / March / April / May / June

LONGITUDINAL EXPERIENCES

Type of experience / Time commitment per week / Number of weeks per year / Amount of time in months (e.g., 40 half days=1 month)

Year 3

Not applicable

BLOCK ROTATIONS

July / August / September / October / November / December / January / February / March / April / May / June

LONGITUDINAL EXPERIENCES

Type of experience / Time commitment per week / Number of weeks per year / Amount of time in months (e.g., 40 half days=1 month)

Option 2 – Block Rotations in Four-Week Stints

Using the template provided below for Appendix C, describe in block form the typical curriculum for fellows by four-week stints including the institution (#1, 2, 3, 4) as listed in PIF Section 2. If you require an extended table, please e-mail your request to .

Year 1

BLOCK ROTATIONS

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13

LONGITUDINAL EXPERIENCES

Type of experience / Time commitment per week / Number of weeks per year / Amount of time in months (e.g., 40 half days=1 month)

Year 2

Not applicable

BLOCK ROTATIONS

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13

LONGITUDINAL EXPERIENCES

Type of experience / Time commitment per week / Number of weeks per year / Amount of time in months (e.g., 40 half days=1 month)

Year 3

Not applicable

BLOCK ROTATIONS

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13

LONGITUDINAL EXPERIENCES

Type of experience / Time commitment per week / Number of weeks per year / Amount of time in months (e.g., 40 half days=1 month)

Option 3 - Other

If your program does not use block rotations, please describe how your curriculum is structured below. Illustrating the structure graphically is encouraged. Programs choosing this option should be aware that using a non-provided template may cause delay in the application review as it may lead to additional reviewer questions.

Appendix D: Goals and Objectives

Using the template provided below, identify and describe all rotations in which fellows participate. THE ACGME COMPETENCY/GLOBAL LEARNING OBJECTIVES, A SAMPLE COMPLETED TABLE, AND ADDITIONAL REFERENCE MATERIALS are available on the UCNS website.

For EACH rotation:

1)name the rotation,

2)describe the rotation (block vs. longitudinal, description of activities, etc.),

3)list the specific learning objectives (see the Goals and Objectives Example, which is available on the UCNS website),

4)link each specific learning objective to corresponding ACGME competency/global learning objective(s) using the numbers from the global objectives table available on the UCNS website (e.g., A.1. for the first objective in the patient care core competency),

5)identify the objective type(s) (knowledge, skills, and attitudes and behaviors)*,

6)identify the assessment type(s) (formative or summative)*, and

7)identify the assessment method(s) (multiple choice questions, test, essay, oral exam, NEX, etc.)*.

*For assistance in writing objectives and determining the objective type(s) and assessment type(s) and method(s), reference the Guide to Writing Goals & Learning Objectives Linked to Assessments: Curricular Alignment, which is available on the UCNS website.

COPY and paste the following FOR EACH PROGRAM ROTATION.

Rotation Name:

Rotation Description:

Specific Learning Objectives
By the conclusion of the program, the fellow must: / ACGME Competency / Objective Type(s) / Assessment
Type(s) / Method(s)

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Appendix E: Formal Didactics

Using the template provided below for Appendix E, list the schedule all didactics in which fellows participate. Indicate which are mandatory and who attends them. The curricular components listed must ensure that all required didactic components that are listed in the program requirements are included in the program’s curriculum.

Didactic Course/Lecture/Conference Title and/or Description
State the course/lecture/conference title and, if the title does not clearly indicate to what portion of the didactic curriculum it relates, please describe how the course meets the program requirements. / Mandatory Course?(Yes/No) / Who attends?
(fellows only; residents and fellows; residents, fellows, and medical students, etc.)
Offered Daily
Offered Weekly
Offered Monthly
Offered Quarterly
Offered Annually

Appendix F: Clinical Components

Using the template provided below for Appendix F, indicate which clinical experiences are included in the program.

Experiences included in the program:
Inpatient ward service / YES / NO
Inpatient consultation service / YES / NO
Outpatient consultation clinic / YES / NO
Outpatient continuity clinic / YES / NO
Emergency room consultation / YES / NO
Nursing home consultation / YES / NO
Nursing home continuity care / YES / NO
Home care / YES / NO
Overnight call / YES / NO
Other (describe):
Other (describe):

Appendix G: Duty Hours Compliance

Please submit a copy of the policy on duty hours and a call schedule to complete Appendix G.

AppendixH: Fellow Meeting Attendance, Research Projects, Publications, and Scholarly Activity

Using the template provided below, list the meeting attendance, research projects, publications, and scholarly activity by fellows for the past three years.

Meeting attendance
Provide a list of meetings that program fellows have attended over the past three years, showing the fellows by name.
Fellow / Meeting / Time period
(over the last three years)
Research projects
List the research projects by program fellows during the past three years.
Fellow / Research project / Time period
(Over thelast threeyears)
Publications
List the publications by program fellows during the past three years.
Fellow / Publication / Time period
(Over the last threeyears)

Scholarly Activity

List the number of scholarly activitiesby fellows during the past three years.

Based on Academic Year Ending / June 30, / June 30, / June 30,
Number of nationally peer-reviewed published articles authored or co-authored by fellows during the year
Number of fellow presentations at regional or national meetings in the year

Appendix I: Evaluation Form Samples

Please provide a sample of a final evaluation used to evaluate fellows completing the program for Appendix I. This final evaluation should demonstrate the fellow’s competence to practice as an independent practitioner in the subspecialty.

Appendix J: Neuroimaging Specific

Please respond to the following:

Please indicate if the following resources are available to the program:

Magnetic Resonance Scanner Yes No
If Yes, is MRS capable of performing echoplanar imaging? Yes No

Computed Tomography Scanner Yes No

Space for image display and interpretation Yes No

Facilities for physiological monitoring Yes No

Facilities for emergency ventilation and cardiac life support Yes No

Teaching file containing at least 500 representative Neuroimaging cases, with

case histories and images, covering a wide variety of disorders Yes No

Estimate the number of images on which fellows will interpret and provide written reports:

MRI images and written reports:

CT images and written reports:

Document how the program will teach the following areas of study. Refer to the Neuroimaging Core Curriculum for the specific details required in each.

Technical aspects/Physics:

Clinical aspects/Applications:

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