Application for GMEC Approval of a Non-Accredited Fellowship Program
BACKGROUND: All clinical training programs within the UW School of Medicine (UWSOM) that provide
postgraduate medical education must be accredited by the Accreditation Council for Graduate Medical
Education (ACGME), approved by the relevant American Board of Medical Specialties (ABMS) or be
approved by the UW Graduate Medical Education Committee (GMEC).
APPLICATIONS FOR NEW AND EXISTING PROGRAMS: This application is for a postgraduate medical
education clinical training program applying for approval by the UW GMEC. For new programs, the
program must be a sub-specialty for which ACGME accreditation or ABMS board approval is not
available. UW GMEC approval must also be sought for established non-accredited programs that have
not obtained and do plan to obtain ACGME accreditation or ABMS board approval. Approval by a
professional organization or endorsement by a body other than the ACGME or Board is NOT sufficient
to consider the program accredited.
GENERAL INSTRUCTIONS
All sections of the form applicable to the program must be completed in order to be accepted for review.
The information provided should describe the proposed program. For items that do not apply indicate
N/A in the space provided. If any requested information is not available, an explanation should be given
and it should be so indicated in the appropriate place on the form.
Please review the GMEC Approved (Non-ACGME Accredited) Programs Policy and Procedure on the
GME website at www.gme.washington.edu. If questions, contact Gabrielle Pett, Director of GME, at
nathangl@uw.edu or 206.543.0069.
Send completed application to the GME Office at 850 Republican St., C-432, Box 358047 or via email
at uwgme@uw.edu.
Note that the process takes approximately two months from the time the application is received until it
is evaluated by the GMEC-Approved Fellowship (GAF) Subcommittee, which is a subcommittee of the
UW GMEC.
Application for GMEC Approved Fellowship Program p. i
Attach the following documents to the application:
1. Program policy on eligibility and selection of fellow(s).
2. Policy for supervision of fellow(s) (addresses fellows’ responsibilities for patient care and
progressive responsibility for patient management and faculty responsibilities for supervision)
3. Program policies and procedures for fellow(s)’ duty hours, if applicable.
4. Program policy on moonlighting, if applicable.
5. Program policy on effects of leave on board eligibility, if applicable.
6. Overall educational goals for the program.
7. A sample of competency-based goals and objectives for one assignment at each educational
level.
8. All Program Letters of Agreement (PLAs) for non-UW Medicine or Seattle Children’s based
training experiences.
9. A copy of the forms that will be used to evaluate fellow(s) at the completion of each assignment.
10. Copies of tools the program will use to provide objective assessments of competence in patient
care, medical knowledge, practice-based learning and improvement, interpersonal and
communication skills, professionalism, and systems-based practice.
11. A copy of the form that will be used to document the semiannual evaluation of the fellow(s) with
feedback.
12. A copy of the final summative evaluation of fellow(s), documenting performance during the final
period of education and verifying that the fellow has demonstrated sufficient competence to
enter practice without direct supervision.
13. A copy of the form that fellow(s) will use to evaluate the faculty.
14. A copy of the form that fellow(s) will use to evaluate the program.
15. Written program requirements defined by the specialty society or other body, if applicable.
16. Letter from Department Chair confirming appointment of fellowship director and percentage of
protected time (i.e., FTE) devoted to program duties.
17. Letter(s) of endorsement from Program Director(s) of other programs that may be impacted by
the fellowship program, if applicable.
18. Image of Program Director’s signature for the program’s graduation certificate (in lieu of wet ink
signature).
Application for GMEC Approved Fellowship Program p. ii
PROGRAM INFORMATION
Program name:
Department:
Division:
Program Director:
Address:
Phone:
Email:
Program Administrator:
Address:
Phone:
Email:
Requested start date (or date fellowship established):
Duration of training:
Number of positions/year:
Signature of Program Director (and date):
Signature of Core Residency Program Director (and date):
Signature of Department Chair (and date):
Signature of Department Director (and date):
1. Is endorsement/approval of the fellowship available by: ☐ Specialty Society ☐ Other: __________
If “YES”, does the program plan to apply for approval? .......................................... ☐ YES ☐ NO
Or attach the approval letter if already approved.
2. Is accreditation available through the: ☐ ACGME ☐ ABMS ☐ Other: _______________________
If so, why does the fellowship not plan to seek accreditation?
TRAINEES
3. How will trainees by appointed (check all that apply)?
☐ Senior Fellow (0445)
☐ Senior Fellow Trainee (0442)
☐ Acting Instructor (0124)
☐ Other: ___________________
4. What percentage of time will fellow(s) devote to training activities versus non-supervised attending
responsibilities?
Application for GMEC Approved Fellowship Program p. 1
5. Have fellow(s) already been selected for the next academic year? ............................. ☐ YES ☐ NO
If “YES”, what is the fellow(s) start date? .................................................................. (__/__/____)
TRAINING SITES
6. What are the participating sites of the program?
Site #1:
Site #3:
Site #2:
Site #4:
RESOURCES
7. Describe the adequacy of program administrative support (e.g., FTE).
8. How will the fellow(s) stipend and benefits be funded (e.g., hospitals, SOM, department, grant,
billing, combination)? Please describe the funding process.
9. What is the proposed annual stipend by training level?
FACULTY
10. Describe the adequacy of program faculty (e.g., description of current faculty expertise).
11. Physician & Non-Physician Faculty Roster
Name
(Position)
073015
Average Hours Per Week Spent On:
Based
Primary and
Primarily
Secondary
Clinical
Didactic
Degree at Site # Specialties/Fields Supervision Admin Teaching Research
Application for GMEC Approved Fellowship Program p. 2
073015
Application for GMEC Approved Fellowship Program p. 3
CURRICULUM & EVALUATION
12. Are there written requirements defined by the specialty society or other body?............ ☐ YES ☐ NO
If “YES”, please attach the written requirements.
13. Didactic curriculum
a. Intradepartmental activities
Activity
Lectures
Conferences or Seminars
Morbidity and Mortality
Conferences
Journal Club
# Per Year
Attendance Obligatory Attendance Obligatory
for Faculty
for Fellows
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
☐ YES ☐ NO
b. Provide provide your didactic schedule below or attached (including lectures, seminars,
conferences, and other didactic exercises planned for the fellowship).
Date
Title
Instructor
Check as appropriate
Faculty Fellow Guest
c. Describe the fellow(s)' expected participation in planning and conducting conferences and other
teaching activities.
d. Will fellows be relieved from clinical duties to attend didactics? .............................. ☐ YES ☐ NO
If “YES”, by whom?
e. Will the fellow attend didactics when functioning as an attending (if applicable)? ... ☐ YES ☐ NO
14. Describe the fellow(s)’ teaching role and/or supervisory responsibilities of other trainees.
073015
Application for GMEC Approved Fellowship Program p. 4
15. Describe the expectations of fellows with regard to scholarly activities, including research
opportunities and ongoing projects that will be available to the fellow(s).
16. What provisions will be made for fellow(s) to attend local, regional, and national meetings?
17. Are there adequate clinical resources to support the curriculum?................................. ☐ YES ☐ NO
18. Are there adequate research resources to support the curriculum? ................. ☐ YES ☐ NO ☐ N/A
19. Describe how fellow(s)’ performance will be evaluated.
20. Will fellow(s) be formally evaluated in writing at least quarterly? .................................. ☐ YES ☐ NO
21. Will fellow(s) receive a formal semi-annual evaluation? ............................................... ☐ YES ☐ NO
22. Will the program use MedHub for evaluation management? ........................................ ☐ YES ☐ NO
If “NO”, how will evaluations be tracked and monitored?
073015
Application for GMEC Approved Fellowship Program p. 5
23. Block Diagram
The purpose of a block diagram is to give the GAF Subcommittee an overview of what takes place during each year of training.
EXPERIENCES OF ROTATIONS
 In each one month block indicate the following:
(1) the type of activity: educational rotation (i.e., ED, Anes), vacation, or attending duties (ATT)
(2) percentage of clinical (C) and research (R) time (i.e., 50% C; 50% R)
(3) the training site in which the activity occurs
 Provide a key/legend for the abbreviations used (i.e., ED = Emergency Department)
 Add additional years if more than one year of training
Example
Month
Experience
or rotations
1
2
3
4
5
6
7
8
9
10
11
Res.
ED
ED
ED
Anes
Trauma
ELEC
ELEC
ELEC
Res.
Res.
20% (C)
100% (C) 100% (C) 100% (C) 100% (C) 100% (C) 100% (C) 100% (C) 100% (C)
100% (R) 100% (R)
80% (R)
HOSP1 HOSP1 HOSP1 HOSP1 HOSP2 HOSP1 HOSP1 HOSP2
HOSP2 HOSP1
HOSP1
ONE YEAR BLOCK DIAGRAM
1
2
Month
3
4
5
6
7
8
9
10
11
12
VAC
12
Experience
or rotations
Total number of clinical months _____________
Total number of research months ____________
073015
Application for GMEC Approved Fellowship Program p. 6
RECRUITMENT
24. Describe the marketing and recruitment plan for the program, including the size of the candidate
pool, how the program will be advertised, etc.
25. Will the program participate in an organized national application system? ................... ☐ YES ☐ NO
If “YES”, which?
☐ ERAS
☐ Board
☐ Other: ___________________
26. Will the program participate in organized match? ......................................................... ☐ YES ☐ NO
If “YES”, which?
☐ NRMP
☐ SF Match
☐ Special Society: _______________ ☐ Other: _______________
27. Will the program accept foreign nationals requiring a visa? .......................................... ☐ YES ☐ NO
If so, which type? ☐ J-1 ☐ H-1B
CERTIFICATION
28. Will the program issue a UWSOM graduation certificate for fellows who successfully complete the
program? .................................................................................................................... ☐ YES ☐ NO
29. Does training lead to additional opportunities for board certification/CAQ? .................. ☐ YES ☐ NO
PROGRAM IMPACT
30. Describe anticipated positive and negative impacts on existing accredited and/or non-accredited
programs (e.g., competition for case volumes or space, increased teaching opportunities). Please
consider impacts both on programs associated with the core specialty, as well as other specificities
that share similar cases or spaces. Address how any negative impacts will be mitigated.
31. How will this program contribute to the educational mission of UW Medicine, Seattle Children’s,
Seattle Cancer Care Alliance, or the VA Puget Sound Healthcare System?
32. Is there a regional and/or national workforce need in this specialty?
073015
Application for GMEC-Approved Fellowship (GAF) Program p. 7