New Application: Adolescent Medicine
Review Committee for Pediatrics
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
COMMON SUBSPECIALTY SECTION
FACULTY RESEARCH
1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary.
[PR II.B.5.b)]
# of current
IRB approved
research
Name
projects
Program Director:
Total # of
current
funded
research
projects
# of current
research
projects with
peer review
funding
(subset of
total # in
previous
column)
#
presentations
at national
scientific
# publications
meetings in in peer review
the last 5
journals in the
years
last 5 years
Key Faculty:
Research Mentors Who Are Not Key Faculty:
2. List active research projects in the subspecialty. Add additional rows as necessary.
Project title
Funding
source
Put an “X for
funding
awarded by
peer review
process
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Years of
funding
(dates)
Faculty investigator and
role in grant (i.e. PI, Co-PI,
Co-investigator)
Updated 4/2015
Page 1 of 11
RESEARCH RESOURCES
1. Does the program provide research laboratory space and equipment? (if appropriate) [PR II.D.]
.................................................................................................................................... ☐ YES ☐ NO
2. Does the program provide financial support for research? ........................................... ☐ YES ☐ NO
3. Does the program provide computer and statistical consultation services? .................. ☐ YES ☐ NO
PROGRAM CURRICULUM
Goals and Objectives
Place an ‘X” in the box before the applicable response. [PR IV.A.2.]
Are there goals and objectives for all training
☐ YES ☐ NO
experiences?
Are they rotation and level specific?
☐ YES ☐ NO
How are they distributed?
☐ Hard Copy ☐ Electronic or web-based
If not web-based, when are they distributed to
☐ Prior to Each Rotation
☐ Annually
fellows?
☐ Once in Handbook
☐ Other
If not web-based, when are they distributed to
☐ Prior to Each Rotation
faculty?
☐ Annually
☐ Other
If web-based, do you send out reminders to access ☐ YES ☐ NO
them?
If yes, when do you send them?
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Collaboration between Programs
Are there meetings among the core Program
Director and subspecialty Program Directors?
How often do these meetings occur?
Who is typically involved in these meetings?
(check all that apply)
☐ YES ☐ NO
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☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties
General Subspecialty Curriculum
Topic
e.g., Biostatistics
Basic science as
related to the
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Research
Course
14
X
Click here to
#
☐
☐
☐
enter text.
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 2 of 11
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Topic
application in clinical
subspecialty practice
Clinical subspecialty
Click here to
#
☐
☐
☐
content
enter text.
For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for
fellows in developmental and behavioral pediatrics), enter N/A into column 1.
Biostatistics
Click here to
#
☐
☐
☐
enter text.
Lab research
Click here to
#
☐
☐
☐
methodology (if
enter text.
appropriate)
Clinical research
Click here to
#
☐
☐
☐
methodology
enter text.
Study design
Click here to
#
☐
☐
☐
enter text.
Grant preparation
Click here to
#
☐
☐
☐
enter text.
Preparation of
Click here to
#
☐
☐
☐
protocols for
enter text.
institutional review
board
Principles of evidenceClick here to
#
☐
☐
☐
based medicine/
enter text.
Critical literature
review
Quality Improvement
Click here to
#
☐
☐
☐
enter text.
Teaching skills
Click here to
#
☐
☐
☐
enter text.
Professionalism/Ethics
Click here to
#
☐
☐
☐
enter text.
Cultural Diversity
Click here to
#
☐
☐
☐
enter text.
Systems-based
Click here to
#
☐
☐
☐
practice (economics of
enter text.
healthcare, practice
management, clinical
outcomes, etc.)
Conferences
1. List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the
subspecialty training program. Identify the "SITE" by using the corresponding number as appears
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 3 of 11
on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and
whether conference attendance is required (R) or optional (0). List the planned role of the fellow in
this activity (e.g., conducts conference, presents case and participates in discussion, case
presentation only, participation limited to Q&A component, etc.). Add rows as necessary.
Conference
Site #
Frequency
R/O
Role of the Fellow
2. Describe the mechanism that will be used to ensure fellow attendance at required conferences.
State the degree to which faculty attendance is expected, and how this will be monitored.
Limit the response to 50 words
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Scholarship Oversight Committee
1. Will there be a scholarship oversight committee for every fellow? ................................ ☐ YES ☐ NO
2. How often will the committee meet with the fellow? ................................................... # times per year
Fellow Research Activities
1. Describe how the program will ensure a meaningful supervised research experience for the fellows,
beginning in their first year and extending throughout their training.
Click here to enter text.
2. If faculty outside the division will be actively involved in mentoring the fellows, identify the mentors
and describe how liaisons will be created between these mentors and the fellows that allows for
meaningful accomplishment of research.
Click here to enter text.
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 11
SPECIALTY-SPECIFIC SECTION
OTHER PROFESSIONAL PERSONNEL
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site. [PR Int.A.3.]
Team Members
Psychology
Social Work
School Systems/ Education
Public Health
Chemical Dependency
Nutrition
Pharmacology Toxicology
Site #1
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Site #2
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Site #3
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Site #4
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2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
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PROGRAM PERSONNEL AND RESOURCES
Inpatient Data [PR VII.C.3.]
1. Provide the following information for the most recent 12-month period. Note the same timeframe
should be used throughout the forms.
Inclusive Dates:
From: Click here to enter a date.
To: Click here to enter a date.
Regardless of whether there is a separate adolescent medicine service, in #1 and #2 below,
separate out those admissions for whom the fellows have primary care responsibility from those
being seen only in consultation.
Inpatient
1. Total number of admissions for which
the adolescent medicine service
assumed primary responsibility
2. Total number of consultations by
adolescent medicine specialists on
other inpatient services
Total Number of Admissions &
Consultations (Total of line 1 and 2)
3. Number of admissions (from the row
above) requiring follow-up care as
outpatients by adolescent medicine
service
Site #1
Site #2
Site #3
Site #4
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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2. Identify the type of inpatient settings in which fellows will participate in addressing the needs of
hospitalized adolescents by placing an X in the box under the appropriate participating site. For
inpatient services indicate the number of available beds.
Inpatient
General Pediatric Unit
Intensive Care Units
Separate Adolescent Medicine Unit
Psychiatric Unit
Detoxification Unit or Substance Abuse Facility
Inpatient Services
Other: Click here to enter text.
Other: Click here to enter text.
Site #1
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#
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Site #2
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#
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Site #3
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Site #4
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#
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3. List 50 consecutive admissions and/or consultations in which the adolescent medicine service
participated. Identify the time period during which these admissions/consultations occurred. The
date range should occur within the same 12-month period used in previous sections. The dates
must begin on the date the first patient on the list was admitted and end with the date the 50th
patient was admitted, (e.g., July 1, 2014 through October 20, 2014). Submit a separate list for each
site that provides required rotations. Use additional tables as necessary.
Site Name:
Inclusive Dates: From (mm/dd/yy):
Patient ID
Number Age
Primary Diagnosis
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To (mm/dd/yy):
Secondary Diagnosis
Adolescent Issues
Updated 4/2015
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Patient ID
Number Age
Primary Diagnosis
Secondary Diagnosis
Adolescent Issues
List of Continuity Experience Diagnoses
List 50 CONSECUTIVE patient visits to a representative setting used for fellows’ continuity experience.
(This list can be consecutive patient visits from one fellow’s log or consecutive patient visits to one site.)
The date range should occur within the same 12-month period used in previous sections. The dates
must begin on the date the first patient on the list was admitted and end with the date the 50th patient
was admitted, (e.g., July 1, 2014 through October 20, 2014). Use additional tables as necessary.
Clinical Site:
Inclusive Dates:
Patient ID
Number
Age
From (mm/dd/yy):
Primary Diagnosis
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To (mm/dd/yy):
Secondary Diagnosis
Adolescent Issues
Updated 4/2015
Page 7 of 11
Patient ID
Number
Age
Primary Diagnosis
Secondary Diagnosis
Adolescent Issues
Ambulatory Adolescent Medicine Training Sites
List the name of setting used to address core knowledge areas for each participating site listed in ADS
as well as all sites for fellows’ continuity experience. Designate continuity clinic sites with an asterisk
(*). Also list the duration of experience, number of sessions, annual number of patient visits, and role of
fellow in care of patients – designate as: primary provider (PP), consultant (C), observer (O),
multidisciplinary care team member (T), and counselor (CS). Add rows as necessary.
Name of Setting Used to
Address Core Knowledge
Areas
Duration of
Experience (in
weeks/year)
Number of
Sessions Per
Week Per
Fellow
Annual number of
patient visits (State
N/A if non-medical
sites)
Role of
Fellow in
Care of
Patients
EDUCATIONAL PROGRAM [PR VIII]
Specialty Experiences
Identify the training sites (e.g. site, clinics, offices, community agencies, schools, etc.) and learning
activities (clinical experience, conference series, self-directed learning modules, small group
discussions, journal club, workshops, etc.) used to address the required core knowledge areas:
Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 8 of 11
Core Knowledge Area
Physical, physiologic, and
psychosocial changes
associated with pubertal
maturation and its disorders
[PR VIII.B.1.a)]
Organ-specific conditions
frequently encountered during
the teen-age years
[PR VIII.B.1.b)]
The effects of adolescence on
preexisting conditions
[PR VIII.B.1.c)]
Mental illness of adolescence
(including
psychopharmacology,
psychophysiologic disorders,
and principles of
psychotherapy/counseling
[PR VIII.B.1.d)]
Family dynamics, conflicts,
problems, and effective
parenting practices
[PR VIII.B.1.e)]
Adolescent parenthood
[PR VIII.B.1.f)]
Disorders of cognition,
learning, attention, and other
areas affecting education
[PR VIII.B.1.g)]
Social and emotional
development of the
adolescent, including
cultural/ethnic diversity
[PR VIII.B.1.h)]
Chronic handicapping
conditions, including medical
management of chronic illness
complicated by psychological
factors [PR VIII.B.1.i)]
Disorders of the endocrine
system and metabolism
[PR VIII.B.1.j)]
Sexuality, including sexual
identity, development and
sexual health problems
[PR VIII.B.1.k)]
Sexually transmitted infections
List the learning
activities used to
address the core
knowledge area
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Identify the corresponding
setting in which these
Year(s) of
learning activities take place Training
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Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 9 of 11
Core Knowledge Area
(diagnosis, treatment, and
prevention) [PR VIII.B.1.l)]
Reproductive health issues of
males and females (e.g.
menstrual disorders,
gynecomastia, contraception,
pregnancy, fertility)
[PR VIII.B.1.m)]
Nutrition, including normal
needs, health problems and
deficiencies, and nutritional
needs of special populations
[PR VIII.B.1.n)]
Health promotion, disease
prevention, screening, and
immunizations
[PR VIII.B.1.o)]
Infectious diseases, including
epidemiology, microbiology,
and treatment [PR VIII.B.1.p)]
Pharmacology and toxicity
[PR VIII.B.1.q)]
The detection, evaluation, and
initial management of
substance abuse problems,
including alcohol and tobacco
[PR VIII.B.1.r)]
Eating disorders (e.g., obesity,
anorexia nervosa, and bulimia)
[PR VIII.B.1.s)]
Social/environmental
morbidities, including physical
and sexual abuse, risk-taking
behaviors, injuries, sexual
assault, and violence
[PR VIII.B.1.t)]
Juvenile justice
[PR VIII.B.1.u)]
Sports medicine
[PR VIII.B.1.v)]
Legal and ethical issues,
including confidentiality and
advocacy [PR VIII.B.1.w)]
Interviewing/short-term
counseling skills for teens and
their parents [PR VIII.B.1.x)]
Public health issues including
List the learning
activities used to
address the core
knowledge area
Identify the corresponding
setting in which these
Year(s) of
learning activities take place Training
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Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 10 of 11
Core Knowledge Area
demographics, social
epidemiology, populationbased interventions, and
adolescent health promotion
[PR VIII.B.1.y)]
Financing adolescent health
care in public, private and
academic managed care
environments [PR VIII.B.1.z)]
Sleep and sleep disorders
[PR VIII.B.1.aa)]
List the learning
activities used to
address the core
knowledge area
Identify the corresponding
setting in which these
Year(s) of
learning activities take place Training
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IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
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Adolescent Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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