NEUROIMAGING

PROGRAM ACCREDITATION APPLICATION

PROGRAM INFORMATION FORM (PIF)

FOR NEW APPLICATIONS ONLY

Last revised: 12-22-10

A. INTRODUCTION

The mission of the United Council for Neurologic Subspecialties (UCNS) is to provide an accreditation and certification process for fellowship training programs with the goals of enhancing the quality of training inneurologic subspecialties and the quality of patient care. The Accreditation Council (AC) strives to develop evaluation methods and processes that are valid, effective, fair, open and ethical. The AC 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 AC 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 making an initial application only.

All programs, new and existing, must complete the entire Program Information Form.

For new training programs where statistical data are not available, e.g., number of graduates, you should mark the section as “NA” (not applicable).

The PIF and Appendix A-G template should be downloaded and completed off-line. The PIF question fields should 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. Once completed, submit the PIF form and Appendices A-G document electronically via e-mail to the UCNS . The UCNS will send a confirmation acknowledging receipt of the application. Should you require additional space in specific fields, please e-mail the UCNS.

The Program Director is responsible for the content of the completed form and the information will not be considered complete without the Program Director’s signature.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 should be given in the appropriate place on the form.

Many items require a composed response to a specific question. Please respond briefly and concisely.

The form also includes requests for the following additional data. Please use the Appendix A-G template to provide this information.

Appendix A:participating institution letter from Department Chair(s) of the participating institution (not the full affiliation agreement; not Program Letter of Agreement)

Appendix B:one page curriculum vitae (Program Director and faculty)

Appendix C:list of clinical conferences at each institution; list of clinical lectures, conferences, courses in other areas; list of other lectures

Appendix D:list of Neuroimaging meetings attended by fellows

Appendix E:list of research projects by fellows

Appendix F:list of publications by fellows

Appendix G:evaluation form samples

Please do not attach any unnecessary materials such as reprints, brochures, annual reports, schedules, minutes of meetings and conferences, etc. The UCNS considers only the information requested on the PIF form and provided in the appendices. Any extra material not requested will be discarded.

C. APPLICATION FEE

The UCNS has two program application categories: New Applicant and Continuing Applicant. You are applying for program accreditation as a New Applicant.

New Applicant$3150 Application Fee ($1150 first-year accreditation fee +

$2000non-refundable application fee)

The accreditation year is the academic year, July 1 through June 30. An annual accreditation fee of $1150will be assessed. Fees are subject to change.

D. PAYMENT

The UCNS accepts checks (or money orders) only at this time. Please submit payment in US funds (payable to United Council for Neurologic Subspecialties) to the UCNS Executive Office, 1080 Montreal Avenue, Saint Paul, MN 55116. Please indicate the subspecialty and name of the program on the payment.

E. APPLICATION DEADLINE

The 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. PROGRAM SITE REVIEW

A site review of the program will not normally be required for the first application of programs. Should the UCNS determine that a site visit is necessary, you will be notified and provided additional information.

G. ADMINISTRATIVE STAFF CONTACTS FOR QUESTIONS

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

H. GLOSSARY OF TERMS

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

I. TABLE OF CONTENTS

Section
1 / Program Information
1.A / Program Identification
1.B / Program Director Information
2 / Institutional Affiliates
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 (3) Years
3.D / Fellows Completing the Program in the Last Three Years
4 / Personnel
4.A / Program Director
4.B / Program Teaching Staff
4.C / Other Teaching Staff
5 / Facilities and Resources
5.A / Facilities
5.B / Library Facilities
6 / Educational Program
6.A / Curriculum
6.B / Seminars and Conferences
6.C / Educational Program
6.D / Program Policies
7 / Research and Scholarly Activity
7.A / Fellow Meeting Attendance
7.B / List of Research Projects by Fellows
7.C / List of Publications by Fellows
7.D / Scholarly Activity Summary
8 / Evaluation
8.A / Fellow Evaluation
8.B / Faculty Evaluation
8.C / Program Evaluation
8.D / Curriculum Development
8.E / Curriculum Evaluation
9 / Signatures
Appendix A:participating institution letter(s) from department chair(s) of participating institution(s)
(not the full affiliation agreement; not Program Letter of Agreement)
Appendix B:one page curricula vitae (Program Director and faculty)
Appendix C:list of clinical conferences at each institution; list of clinical lectures, conferences, courses in other areas; list of other lectures
Appendix D:list of Neuroimaging meetings attended by fellows
Appendix E:list of research projects by fellows
Appendix F:list of publications by fellows
Appendix F:evaluation form samples

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/will you have each year?
How many years is the fellowship?
10 Digit UCNS Program ID# (for office use only):

B.Program Director (PD) Information

Name:
Title:
Address:
City, State, Zip code:
Telephone: / FAX: / Email:
Date Program Director First Appointed:
Term of Program Director Appointment:
Primary Specialty Board Certification: / Most Recent Certification Date:
Secondary Specialty Board Certification: / Most Recent Certification Date:
Number of years spent teaching in GME in this subspecialty:
Is the Program Director a full-time staff member of the sponsoring institution? YES NO
Does the Program Director hold a current license to practice medicine in the state of the sponsoring institution?
YES NO
Is the Program Director ABMS or RCPSC certified in neurology, child neurology,neurosurgery or radiology?
YES NO
Is the Program Director UCNS certified in Neuroimaging? YES NO
Is the Program Director based at primary teaching institution? YES NO
How many hours per week does the Program Director spend in:
Clinical Supervision: / Administration: / Research: / Didactics/Teaching:
Is Program Director also Department Chair? YES NO
If No, Chair Name:

SECTION 2. INSTITUTIONAL AFFILIATES(Program Requirements II, A, B)

SPONSORING INSTITUTION: (Institution #1) -The university, hospital, or foundation that has ultimate responsibility for this program
Name of Sponsor:
Address: / Is there a sponsoring core residency program?
YES NO
City, State, Zip code:
Type of Institution: (e.g., Teaching Hospital, GeneralHospital, MedicalSchool):
Ownership Type: (e.g., State, Corporation, Church):
Is Institution ACGME Accredited Yes No Length of Accreditation: Next Review Date:
Name of Individual Responsible for Oversight of Training at this Institution (Program Director):
Does SPONSOR have an affiliation with a medical school (could be the sponsoring institution)? / YES / NO
If Yes
Name of MedicalSchool #1:
Name of MedicalSchool #2:
PRIMARY INSTITUTION (Institution #2)If different than the sponsoring institution
Name:
Address:
City, State, Zip Code:
Name of Individual Responsible for Oversight of Training at this Institution:
Type of Institution: (e.g., Teaching Hospital, GeneralHospital, MedicalSchool):
PARTICIPATING INSTITUTION (Institution #3)
Name:
Address:
City, State, Zip Code:
Distance between Institutions 1 & 3: / Miles: / Minutes:
Type of Rotation (select one) / Elective / Required / Both
Length of Fellows Rotation (in months) / Year 1: / Year 2:
Name of Individual Responsible for Oversight of Training at this Institution:
Type of Institution: (e.g., Teaching Hospital, GeneralHospital, MedicalSchool):
Brief Educational Rationale for Use of this Institution:
PARTICIPATING INSTITUTION (Institution #4) If more than two participating institutions, e-mail .
Name:
Address:
City, State, Zip Code:
Distance between Institutions 1 & 4: / Miles: / Minutes:
Type of Rotation (select one) / Elective / Required / Both
Length of Fellows Rotation (in months) / Year 1: / Year 2:
Name of Individual Responsible for Oversight of Training at this Institution (Site Coordinator):
Type of Institution: (e.g., Teaching Hospital, GeneralHospital, MedicalSchool):
Brief Educational Rationale for Use of this Institution:
RELATED CORE PROGRAM IN NEUROLOGY
Name of Institution or Hospital:
Address:
City, State, Zip Code:
Date Program Approved for Accreditation:
Next Review Date:
Name of Program Director:
Total Number of Faculty:

SECTION 3. FELLOWS INFORMATION

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

Positions / Year 1 / Year 2 / 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 fellow finished:
For programs that have never had fellows, complete with “N/A”.

Note: The total number of fellows should not exceed the 1:1 faculty to fellow ratio for the fellowship program. Faculty included in determining the ratio are those listed in section 4.B. See Program Requirements III.B.

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

1. List all fellows actively enrolled in this program as of August 31 of current academic year (see Section 3.A). List names alphabetically. Indicate fellows accepted as transfer with an asterisk (*).

YEAR ONE

Name / MedicalSchool / Prior GME trainingprogram / ABPN/RCPSC eligible or Certified?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO

YEAR TWO

Name / MedicalSchool / Prior GME trainingprogram / ABPN/RCPSC eligible or Certified?
YES NO
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 faculty to fellow ratio. What effect will this have on your faculty to fellow ratio?

C.Aggregate Data on Fellows Completing or Leaving the Program for the Last Three (3) Years (if applicable)

Based on 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 specific reasons 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 (if applicable). List all fellows who have completed all training for this subspecialty based on the last academic year ending June 30,.

Name / Start Date / Actual Date of Completion / Practice Position / ABPN 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,.

Name / Start Date / Actual Date of Completion / Practice Position / ABPN 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,.

Name / Start Date / Actual Date of Completion / Practice Position / ABPN 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, A, B)

  1. Describe the Program Director’s qualifications in neuroimaging. Indicate appropriate qualifications, including subspecialty expertise in neuroimaging and at least five years in post graduate practice, as well as documented clinical, educational and administrative abilities, and experience in his/her field.
  1. Describe the Program Director’s prior experience in the training of medical students or post-doctoral medical or surgical trainees.
  1. Describe how the Program Director is able to foster and optimize multidisciplinary interactions and teaching in neuroimaging within the institution(s).
  1. Give a brief description of the Program Director’s responsibilities and activities. Attach one page curriculum vitae (AppendixB) for the Program Director (use Appendix B form). CVs using the NIH Biographical Sketch format will be accepted as long as it provides current hospital staff privileges.

B.Program Teaching Staff—Neuroimaging (Program Requirements IV, C, D, E)

List all members of the program responsible for core training in Neuroimaging. For those with dual appointments, identify primary appointment (neurologyor other department) in parentheses. See Section 2 for institution numbers.

See Section 2 for institution numbers.

Name, Degree, Title and Position / Privileges at Institution #1,2,3,4 / Full-Time / If Part-time, State / NI Certification
Wks/
Yr / Hrs/
Wk
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:

Attach a one page curriculum vitae (AppendixB) for each of the faculty listed above (use Appendix B form). CVs using the NIH format Biographical Sketch format will be accepted as long as they provide current hospital staff privileges.

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

C.Other Teaching Staff

List other teaching staff regularly involved in teaching fellows, including consultants and basic science faculty. Note their department, title and certifying credentials, and supervisory responsibilities to the program. See Section 2 for institution numbers.

See Section 2 for institution numbers.

Name, Degree, Title and Position / Privileges at Institution #1,2,3,4 / Full-Time / If Part-time, State / NI Certification
Wks/
Yr / Hrs/
Wk
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:
YES / NO / UCNS Certified
UCNS Eligible
Role in Curriculum:

Attach one page curriculum vitae (Appendix B) for members with major teaching responsibilities (use Appendix B form). CVs using the NIH Biographical Sketch format will be accepted.

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

SECTION 5. FACILITIES AND RESOURCES(Program Requirements V, F)

A.Facilities

1.Facilities and resources for training

See Section 2 for institution numbers.

Are the following office space and resources available?

Faculty and Resources / Inst
1 / Inst
2 / Inst
3 / Inst
4
a.NeuroimagingFaculty Offices and Facilities / YES NO / YES NO / YES NO / YES NO
Is there administrative support for the Fellowship & Program Director? / YES NO / YES NO / YES NO / YES NO
b. Fellow Offices and Resources / YES NO / YES NO / YES NO / YES NO
Does each fellow have his/her own office? / YES NO / YES NO / YES NO / YES NO
Are the offices for groups of fellows? / YES NO / YES NO / YES NO / YES NO
Is there dedicated administrative support for fellows? / YES NO / YES NO / YES NO / YES NO
Does the fellow have access to other office equipment such as copiers, slide projectors, PowerPoint, video projection equipment or services to make slides, illustration services? / YES NO / YES NO / YES NO / YES NO
c.Laboratory Facilities / YES NO / YES NO / YES NO / YES NO
d.Magnetic Resonance Scanner / YES NO / YES NO / YES NO / YES NO
e.If available, is MRS capable of performing echoplanar imaging? / YES
NO / YES NO / YES NO / YES NO
f.Computed Tomography Scanner / YES NO / YES NO / YES NO / YES NO
g.Space for Image Display and Interpretation / YES NO / YES NO / YES NO / YES NO
h.Facilities for Physiological Monitoring / YES NO / YES NO / YES NO / YES NO
  1. Facilities for Emergency Ventilation and Cardiac Life Support
/ YES NO / YES NO / YES NO / YES NO
  1. Space, in or adjacent to Examination Room, for Storage of Supplies Used in Invasive Neuroimaging Procedures
/ YES NO / YES NO / YES NO / YES NO

2.Briefly describe conference facilities that will be used for Neuroimaging conferencesat each institution.

3.Briefly describe the space provided for Neuroimaging program faculty and fellow research at each institution. (Program Requirements V, F)

B.Library Facilities

Use the table below to describe the institutional and departmental library holdings and other reference resources at each institution.

See Section 2 for institution numbers.

Are the following facilities and resources available?

Library Facilities / Inst
1 / Inst
2 / Inst
3 / Inst
4
a. Journals
Access to Medline / YES
NO / YES
NO / YES
NO / YES
NO
b. Computer Databases Available / YES
NO / YES
NO / YES
NO / YES
NO
Access in Hospital / YES
NO / YES
NO / YES
NO / YES
NO
Access in Library / YES
NO / YES
NO / YES
NO / YES
NO
24 Hour Access / YES
NO / YES
NO / YES
NO / YES
NO
Access to Major Texts and Full Text Journals / YES
NO / YES
NO / YES
NO / YES
NO
Internet Search Capabilities / YES
NO / YES
NO / YES
NO / YES
NO
c. Library Available on Site / YES
NO / YES
NO / YES
NO / YES
NO
Library with Major Texts in all Areas of Medicine on Site or Nearby / YES
NO / YES
NO / YES
NO / YES
NO
Interlibrary Loan Capability / YES
NO / YES
NO / YES
NO / YES
NO
Textbook Availability / YES
NO / YES
NO / YES
NO / YES
NO
Major NeuroimagingTexts on wards / YES
NO / YES
NO / YES
NO / YES
NO
Major NeuroimagingTexts in clinic / YES
NO / YES
NO / YES
NO / YES
NO
Teleconference Capability / YES
NO / YES
NO / YES
NO / YES
NO
d.Neuroimaging Teaching File with Case Histories and Images with 500 Entry Minimum. (Can Be Electronic) / YES
NO / YES
NO / YES
NO / YES
NO

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