New Application: Pediatric Hematology-Oncology
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
Pediatric Hematology-Oncology
©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 13
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
Click here to enter text.
☐ 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.
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 2 of 13
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
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 3 of 13
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
Click here to enter text.
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.
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 13
SPECIALTY-SPECIFIC SECTION
PROGRAM PERSONNEL AND RESOURCES
Other Professional Personnel
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site. [PR II.C.; VII.B.]
Team Members
Psychology
Social Work
Education
Nutrition
Pharmacy
Site #1
☐
☐
☐
☐
☐
Site #2
☐
☐
☐
☐
☐
Site #3
☐
☐
☐
☐
☐
2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
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Outpatient and Inpatient
1. Indicate the existence/availability of the following by checking the appropriate box. For inpatient
services indicate the number of available beds.
Facility/Service
Separate divisions of hematology and oncology*
Space in an ambulatory setting for optimal
evaluation and care of patients
[PR VII.C.1.]
Outpatient infusion unit
An inpatient area with full pediatric and related
services (including surgery and psychiatry)
staffed by pediatric residents and faculty
[PR VII.C.2.]
A separately staffed unit in the inpatient area
Support services which include radiology
laboratory, nuclear medicine and pathology
[PR VII.C.4.]
PICU (total number of beds)
Site #1
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#
#
#
* Provide a description of the organization if separate divisions are present. Specifically describe
the administrative structure and the teaching role of each division in the training program.
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2. For every facility/service that is not available at any of the sites, provide an explanation below.
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 5 of 13
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Laboratories and Diagnostic Services [PR II.D.; VII.C.]
1. Indicate the availability of the following:
Service
Diagnostic Radiology
Angiography
Nuclear medicine capabilities including MIBG
and cardiac imaging
Computerized tomography
Sonography – abdominal and cardiac
Magnetic resonance imaging
Diagnostic Laboratory
Testing for RBC enzyme deficiencies
Hemoglobin electrophoreses
Evaluation of bone marrow aspirations and
biopsies
HLA and tissue typing
Immunophenotyping
Cytogenetics – karyotyping and molecular
genetics
Hemostasis testing (factor assays and
platelet function testing)
Thrombophilia testing
Administrative Support
Tumor registry
Tumor board
Cancer rehabilitation program
Clinical Programs
Transfusion medicine program
Hemophilia program
Sickle cell/hemoglobinopathy program
Bone marrow/PBSC transplantation program
Solid organ transplantation program
Renal replacement program (e.g., CVVH)
Limb-saving procedures program
Surgical oncology program
Radiation oncology facility that can serve
children
Family Support
Hospice program for children
Parent support group
Residential housing during treatment
Site #1
Site #2
Site #3
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Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 6 of 13
2. If NO is indicated for any of the facilities and/or services in all the institutions above, explain how the
service is provided for patients. If the facility or service is concentrated in one institution, explain
how patients in the other institutions access these services or facilities.
Click here to enter text.
PATIENT POPULATION [PR VII.C.5.]
1. Provide the requested information for the most recent three year period. The same time frame
must be used for all patient data requested in subsequent sections.
Inclusive Dates: From: Click here to enter a date.
To: Click here to enter a date.
Average daily census of patients on the pediatric
hematology-oncology inpatient service averaged
over the last three (3) years
Average number of consultations for
hematology/oncology problems averaged over the
last three (3) years
Average number of outpatient visits for
hematology/oncology patients averaged over the
last three (3) years
Average number of NEW oncology patients (“new”
refers to those who are being seen by
hematologists/oncologists for the first time)
averaged over the last three (3) years
Average annual number of NEW hematology
patients (“new” refers to those who are being seen
by hematologists/oncologists for the first time)
averaged over the last three (3) years
Site #1
Site #2
Site #3
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
2. Provide the following information for the most recent 12-month academic or calendar year for each
site used to provide a specific required experience, such as transplant, cardiology, intensive care,
etc. Duplicate this table as necessary. Note the same timeframe should be used throughout the
forms.
Site #1
Site #2
Site #3
Name of service:
Total number of fellows and residents on the
service
Total number of admissions to the service
Number of new patients admitted each year
(“new” refers to those who are seen by
members of the service for the first time.)
Average length of stay of patients on the
service
Average daily census of patients on the
service, including consultations
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 7 of 13
3. If the program does not meet the required minimum of 60 NEW oncology patients per year, explain
how the fellow will get adequate experience with the breadth and intensity of oncology care. [PR
VII. C.5.b)]
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4. If the program does not meet the minimum of 60 NEW hematology patients per year, explain how
the fellow will get adequate experience with the breadth and intensity of hematology care. [PR VII.
C.5.b)]
Click here to enter text.
5. If the program has a limited number of patients with non-oncologic hematologic disorders, explain
how the fellow will gain exposure to sickle cell disease, hemophilia, and other acute and chronic
hematologic problems. [PR VII. C.5.b).(1)]
Click here to enter text.
EDUCATIONAL PROGRAM [PR VIII.]
Hematologic and Oncologic Experience for All Years of Training
Complete a table for each institution where pediatric hematology or oncology patients are cared for by
fellows in the program. Use the same three years identified in the section above. Duplicate table as
necessary. List only those patients available to fellows.
Site Name:
Inclusive Dates:
From: Click here to enter a date.
To: Click here to enter a date.
Inpatients Over Past
Three Years
Number on Number Seen
Hem/Onc
in
Diagnoses
Service
Consultation
Hematologic Diagnoses And Disorders
1. Hematologic disorders in the
newborn
[PR VIII.A.2.a).(1)]
2. Hemoglobinopathies
[PR VIII.A.2.a).(2)]
a) Sickle Cell disease and
variants;
b) Thalassemias
[PR VIII.A.2.a).(2)]
c) Number requiring long term
transfusion therapy
3. Inherited and acquired disorders of
red cell membrane and red-bloodcell metabolism
[PR VIII.A.2.a).(3)]
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outpatients Over Past
Three Years
Number on Number Seen
Hem/Onc
in
Service
Consultation
Updated 4/2015
Page 8 of 13
Diagnoses
a) Red Cell Membrane (e.g.,
Spherocytosis, elliptocytosis)
b) Disorders of RBC metabolism
(e.g., G6PD, PK)
4. Autoimmune hemolytic anemias
[PR VIII.A.2.a).(4)]
5. Nutritional deficiencies
a) Iron deficiency anemia
[PR VIII.A.2.a).(5)]
b) Other deficiencies (e.g., folate
deficiency, B12 deficiency)
6. Disorders of WBCs
[PR VIII.A.2.a).(6)]
a) Immune neutropenia
b) Inherited disorders of WBC
c) Acquired disorders of white
blood cells
7. Coagulopathies
[PR VIII.A.2.a).(7)]
a) Hemophilias
b) Von Willebrand’s disease
c) Other inherited and acquired
coagulopathies
8. Platelet Disorders
[PR VIII.A.2.a).(8)]
a) Immune thrombocytopenia
b) Acquired and inherited platelet
function defects
c) Other platelet disorders
9. Thrombophilias
[PR VIII.A.2.a).(9)]
a) Congenital thrombophilias
b) Acquired thrombotic disorders
Oncologic Diagnoses And Disorders
10. Leukemias
[PR VIII.A.2.a).(10)]
a) Acute Lymphoblastic
Leukemias
b) Acute myeloid (nonlymphoblastic) leukemias
c) Myelodysplastic syndromes
d) Chronic leukemias
Inpatients Over Past
Three Years
Number on Number Seen
Hem/Onc
in
Service
Consultation
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Outpatients Over Past
Three Years
Number on Number Seen
Hem/Onc
in
Service
Consultation
Updated 4/2015
Page 9 of 13
Diagnoses
11. Lymphomas
[PR VIII.A.2.a).(11)]
a) Hodgkin’s disease
b) Non-Hodgkin’s Lymphomas
12. Neuroblastoma
13. Wilms’ Tumor
[PR VIII.A.2.a).(12)]
14. Soft tissue sarcomas (e.g.,
Rhabdomyosarcoma
leiomyosarcoma)
[PR VIII.A.2.a).(12)]
15. Bone Tumors
[PR VIII.A.2.a).(12)]
a) Osteosarcoma
b) Ewing’s Family of Tumors
(Ewing’s sarcoma, PNET)
16. Hepatoblastoma or Hepatocellular
carcinoma
17. Retinoblastoma
18. Other (specify)
Inpatients Over Past
Three Years
Number on Number Seen
Hem/Onc
in
Service
Consultation
Outpatients Over Past
Three Years
Number on Number Seen
Hem/Onc
in
Service
Consultation
19. Using a bulleted list describe where and how fellows will be exposed to the care of patients in any
category (row) above with less than 3 patients.
 Click here to enter text.
 Click here to enter text.
Transplants
1. Indicate the number of transplants performed on patients 18 years or younger in the training
program for the same 3 year period used the sections above.
Inclusive Dates:
From: Click here to enter a date.
To: Click here to enter a date.
Type of Transplant
Diagnoses
Leukemia
Lymphoma
Solid malignancies
Hematologic
disorders
Allogeneic Allogeneic
Related
Unrelated Autologous
#
#
#
#
#
#
#
#
#
#
#
#
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Source of Stem Cells
Peripheral
Bone
Blood
Umbilical
Marrow
Stem Cell
Cord
#
#
#
#
#
#
#
#
#
#
#
#
Updated 4/2015
Page 10 of 13
Type of Transplant
Diagnoses
Immunologic
disorders
Metabolic disorders
Other (specify)
Number with acute
GVHD
Number with chronic
GVHD
Allogeneic Allogeneic
Related
Unrelated Autologous
#
#
#
Source of Stem Cells
Peripheral
Bone
Blood
Umbilical
Marrow
Stem Cell
Cord
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
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#
2. Using a bulleted list, describe where and how fellows will be exposed to the care of patients in any
category (row) above with less than 3 patients.
 Click here to enter text.
 Click here to enter text.
Ambulatory Pediatric Hematology-Oncology Experience for All Years of Training [PR VII.C.1.]
Provide the following information. In location of experience, include all sites listed in ADS as well as, all
sites for fellows’ continuity experience. Designate continuity clinic sites with an asterisk (*). Add rows as
necessary.
Location of
Experience
Use Site/Other
Setting Identifier
Duration of
Experience
(in wks/yr)
Planned Role
of Fellow in
Care of
Estimated
Patients –
Estimated
Average # of Designate as:
Planned # of Average # of
return
Primary
Sessions per new patients patients per Provider (PP)
week per
per fellow per fellow per
Consultant
fellow
session
session
(C)
1. If the fellow does not have block rotations in an ambulatory setting, explain how fellows will have
the opportunity to provide outpatient care for patients who they treated on the inpatient service and
how they will learn about the medication modifications and complications for patients who are
primarily outpatients.
Limit the response to 250 words
Click here to enter text.
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 11 of 13
Core Curriculum
1. Identify the training sites (Site #) and learning activities (clinical experience, conference series,
journal club, tumor board, etc.) which will be used to address the required core knowledge areas:
Core Knowledge Area
Pain Management
[PR VIII.A.5.]
Laboratory techniques and
data interpretation
[PR VIII.A.9.-10)
Transfusion medicine and
the use of blood products
[PR VIII.A.3.a)]
Integration of surgical and
radiation therapy in
treatment
[PR VIII.A.1.b).(1)]
Use of cooperative group
clinical trials
[PR VIII.A.9]
Selection, acquisition and
use of blood components
[PR VIII.A.3.a)]
List the corresponding
List the learning activities
setting in which these
used to address the core
learning activities take
knowledge area
place
Click here to enter text.
Click here to enter text.
Year(s)
of
Training
#
Click here to enter text.
Click here to enter text.
#
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#
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#
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#
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#
2. Describe how fellows will have structured educational experiences in psychological and
social support of patients, families, and staff, including how fellows will recognize and
manage psychosocial stresses and problems, serve as a member of a multidisciplinary team,
demonstrate skill in communication and counseling, and the provision of comprehensive care
[PR VIII.A.6.a)]
Click here to enter text.
Inpatient Experiences
Describe the responsibilities that fellows will have for inpatients and how and by whom they will
be supervised. [PR VII.C.2.]
Limit the response to 100 words
Click here to enter text.
Outpatient Experiences (If applicable)
1. Describe the responsibilities that fellows will have for outpatients and how and by whom
fellows will be supervised. [PR VII.C.1.]
Limit the response to 100 words
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 12 of 13
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2. Describe the continuity of care experience fellows will receive during their period of
assignment to the outpatient clinic. To what extent will they have the opportunity to provide
outpatient care for patients whom they treated on the inpatient service? [PR VIII.A.7.]
Limit the response to 100 words
Click here to enter text.
Laboratory Experience and Diagnostic Procedures
Provide a description of the method by which fellows will acquire skills and how their competence
is ensured for each of the following:
1. Performance and interpretation of bone marrow aspiration and biopsy; [PR VIII.A.11.a)]
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2. Lumbar puncture with evaluation of cerebrospinal fluid; [PR VIII.A.11.b)]
Click here to enter text.
3. Microscopic interpretation of peripheral blood films; and, [PR VIII.A.11.c)]
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4. Interpretation of other hematologic laboratory diagnostic tests. [PR VIII.A.11.d)]
Click here to enter text.
IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
Click here to enter text.
Pediatric Hematology-Oncology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 13 of 13