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Program Director Transition Request
Program name:
Current program director:
Proposed program director:
Proposed date of transition:
Date proposed program director first appointed
as faculty member in the department:
Proposed term of the appointment:
Proposed program director phone number:
Proposed program director email address for
communicating with the ACGME:
Form completed by (name and title):
Date of submission:
Interim
Permanent
RATIONALE:
Provide a brief statement describing the reason for the proposed change in program director.
If the proposed is an interim term of appointment, please explain.
Will the current program director remain in the program as teaching faculty?
Yes
No
Are there associate/assistant program director(s)?
Yes
No
If yes, please specify the roles, people, and how much time does each devote to the program?
Associate/Assistant Program Director:
SELECTION PROCESS:
Provide a detailed explanation of the selection process (including whether or not it involved a national
search, a brief description of the selection committee, etc.).
Selection process:
QUALIFICATIONS:
Does the nominee meet the ACGME and/or program specific RRC Requirements (e.g., minimum experience as faculty member; length of appointment, etc)? Please check the program’s specific RRC requirements on the ACGME website.
Yes
No
Please summarize the nominee’s qualifications. This may include prior experience as a program director
or other educational leadership position (associate/assistant program director, clerkship director), involvement in the residency/fellowship training program, serving as a member of an education committee,
etc.
Qualifications:
RESOURCES:
Please provide information on how the nominee will be provided with sufficient amount of support for
program administration. Please check the program’s specific RRC requirements on the ACGME website:
Program Director protected time: Specify % time or # of days per week dedicated for the PD role for
which the proposed program director will be compensated:
Administrative support: (Name of Coordinator(s) and FTE(s) of support )
How will the proposed program director responsibilities change, if any, in order to have sufficient time for
the role as Program Director? For example, change in % _____in clerical, administrative, research time.
OTHER COMMENTS:
Please provide any additional comments or details that you may have in support of the nomination.
Other comments:
REQUIRED ATTACHMENTS:
 Candidate’s CV.
 Program Director Job Description (template available).
http://www.partners.org/Graduate-Medical-Education/Program-Directors/ProgramChanges-and-GME-Committee-Oversight.aspx
The job description must include requirements stipulated by the ACGME in both the “Common
Program Requirements” and specialty program requirements. These may include Program Director credentials, time commitment, and specific responsibilities. The job description should also
specify the frequency and manner of evaluation of the program director, in order to ensure that
periodic constructive feedback is provided.
Please return the completed request and all requested documents via email to Irina Knyshevski
(iknyshevski@partners.org) for BWH programs or Diane Sheehan (dsheehan@partners.org) for
MGH programs.
9/25/2012
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