New Application: Pediatric Radiology
Review Committee for Diagnostic Radiology
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
PARTICIPATING SITES
Provide the name and 10-digit program ID of the ACGME-accredited diagnostic radiology program with
which the fellowship program is associated. [PR I.B.3.]
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PROGRAM PERSONNEL AND RESOURCES
Program Director
1. What percentage of time does the program director spend in the subspecialty? [PR II.A.1.b)] ..... # %
2. Will the program director evaluate the fellow(s) at least quarterly, and provide written feedback at
formal semiannual meetings with the fellows? [PR II.A.3.e)] ........................................ ☐ YES ☐ NO
3. Will the program director select and supervise the fellows and work to comply with departmental,
institutional, and ACGME guidelines concerning fellowship issues? [PR II.A.3.f)] ........ ☐ YES ☐ NO
4. Will the program director work with the faculty to organize, continuously evaluate and improve the
fellowship educational program? [PR II.A.3.g)] ............................................................. ☐ YES ☐ NO
5. Will the program director ensure that goals and objectives of specific rotations are distributed to
fellows and faculty? [PR II.A.3.h)]................................................................................. ☐ YES ☐ NO
Faculty
1. Will fellow experience in special imaging, such as ultrasound, cardiac, interventional radiology,
nuclear radiology, computed tomography, and magnetic resonance be supervised by pediatric
radiology faculty? [PR II.B.3.b)] .................................................................................... ☐ YES ☐ NO
2. Will faculty regularly participate in: [PR II.B.3.c)]
a) clinical discussions ................................................................................................. ☐ YES ☐ NO
If yes, indicate frequency ............................................................................................ [Frequency]
b) journal clubs ........................................................................................................... ☐ YES ☐ NO
If yes, indicate frequency ............................................................................................ [Frequency]
c) clinical multidisciplinary conferences ...................................................................... ☐ YES ☐ NO
If yes, indicate frequency ............................................................................................ [Frequency]
d) research conferences ............................................................................................. ☐ YES ☐ NO
If yes, indicate frequency ............................................................................................ [Frequency]
Explain any “no” responses.
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Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
Page 1 of 12
Other Program Personnel
1. Is there a program coordinator available to the program? [PR II.C.1.] .......................... ☐ YES ☐ NO
If no, explain
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2. Does the program coordinator have sufficient time and resources to support the administration and
educational conduct of the program? [PR II.C.1.] ......................................................... ☐ YES ☐ NO
If no, explain
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Resources
1. Patient Data [PR II.D]
Reporting Period (Recent 12month period):
From: Click here to enter a date. To: Click here to enter a date.
Patient Examination Data
Diagnostic Examinations
TOTAL
Adult
Pediatric (Inc. neonatal)
Site #1
Outpatient Inpatient
#
#
Site #2
Outpatient Inpatient
#
#
Site #3
Outpatient Inpatient
#
#
#
#
#
#
Outpatient Only
#
#
#
#
Outpatient Only
#
#
#
#
Outpatient Only
#
#
#
#
#
#
#
#
#
#
#
#
Number of Emergency Room
Radiology Examinations
(included above)
Adult
Pediatric (include neonatal)
Pediatric Admissions
2. Briefly describe the facilities and space, including study space, conference space, and access to
computers, available for the education of fellow. [PR II.D.1.a)]
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3. List the number of units available to fellows in each site. Include units in other departments, e.g.,
cardiology, GI and GU. [PR II.D.1.]
Diagnostic Radiology Equipment
DR and CR radiographic units
Portable radiographic units
Fluoroscopic units
C arm fluoroscopic units
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Site #1
#
#
#
#
Site #2
#
#
#
#
Site #3
#
#
#
#
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Diagnostic Radiology Equipment
Interventional suite
CT scanners in hospital complex (date of last
purchased unit)
CT scanners off site
Ultrasound Equipment
Number of units with color Doppler
Portable units
MRI Scanners
Units on-site in hospital complex
Units intra-operative
Units available off-site
Date of last purchase
Nuclear Radiology Equipment
Single head gamma
Dual head gamma (SPECT/CT)
PET/CT
Uptake probe
Site #1
#
Site #2
#
Site #3
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
4. Provide the data requested below regarding the number of procedures performed at each site that
participates in the program for the most recent 12-month period. [PR. II.D.]
Reporting Period (Recent 12month period):
From: Click here to enter a date. To: Click here to enter a date.
Procedure
Magnetic Resonance Imaging
L-spine with/without contrast
L-spine with contrast
L-spine with/without contrast
Brain with contrast
Brain with/without contrast
Lower extremity w/joint without contrast
Lower extremity w/joint with/without contrast
MRA upper extremity
MRA Lower extremity
Cardiac MR
Fetal MR
TOTAL
Computed tomography
Chest with contrast
Chest without contrast
Abdominal without contrast
abdominal with contrast
pelvis with contrast
pelvis without contrast
CPT Code
Site #1
Site #2
Site #3
72148
72149
72158
70552
70553
73721
73723
73225
73725
75557
72195
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
71260
71250
74150
74160
72193
72192
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
Page 3 of 12
Procedure
CT head without contrast
CPT Code
70450
Site #1
#
#
Site #2
#
#
Site #3
#
#
78740
78815,
78816
78306
#
#
#
#
#
#
#
#
#
#
#
#
74240
74283
49440
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
TOTAL
Nuclear medicine
Nuc cysto
PET/CT – skill to thigh & whole body
Bone scan, whole body
TOTAL
Fluoro
UGI
Therapeutic enema
G-tube placement
Ultrasound
Renal
Abdomen
Head
Hips
Fetal
76770
76700
76506
76886
76815
TOTAL
Radiography
Chest 1 view
Chest 2 view
Skeletal survey
71010
71020
77075
TOTAL
#
#
#
#
#
5. Does the sponsoring institution also sponsor an ACGME-accredited pediatric residency?
[PR II.D.2.] ................................................................................................................... ☐ YES ☐ NO
6. List the ACGME-accredited pediatric residency program(s), and pediatric medical and surgical
fellowship programs in the institution and the number of fellows in each. Add additional rows as
necessary. [PR II.D.2.]
ACGME-Accredited Programs
Residents/Fellows
7. How many pediatric surgeons are available at the sponsoring institution? [PR II.D.2.] ................. [ # ]
8. How many pediatric pathologists are available at the sponsoring institution? [PR II.D.2.] ............. [ # ]
9. List other types of pediatric medical and surgical subspecialists available at the sponsoring
institution. [PR II.D.2.]
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Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
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10. How will the program director ensure the subspecialty program in pediatric radiology will not dilute
or detract from the educational opportunities available to residents in the core diagnostic radiology
resident program? [PR III.B.3.]
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11. Briefly describe the interaction the fellowship program will have a diagnostic radiology residency
program. [PR III.B.5.]
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Medical Information Access
Describe resources available for point of service teaching and learning utilized during read out session.
The description should include the availability of electronic resources. [PR II.E.]
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FELLOW APPOINTMENTS
1. What is the total number of radiology residents that rotate through pediatric radiology per year?
[PR I.B.3; III.B.2] .......................................................................................................................... [ # ]
a) Average length of rotation: ............................................................................................... [Length]
2. If the pediatric radiology program is sponsored by a diagnostic radiology residency program, explain
the distinction between the residents and the pediatric radiology fellows in terms of clinical activities
and level of responsibility. [PR III.B.4.]
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3. Will pediatric radiology fellows have shared experiences with pediatric residents and fellows in
pediatric-related subspecialties (i.e. surgery, pathology, neonatology, general pediatrics, and
adolescent medicine) and cardiology? [PR III.B.5.a)] (Note that programs will not be cited for failure
to provide this experience) ........................................................................................... ☐ YES ☐ NO
EDUCATIONAL PROGRAM
For the competency tables below, examples of evaluation methods for competence may include: direct
observation, global assessment, multisource assessment, practice/billing audit, patient survey,
record/chart review, review of patient outcomes, simulations/models, structured case discussion, inhouse written examination, In-training examination, oral examination and computer-based learning.
Patient Care
1. For the patient care and procedural areas listed in the table below, identify the learning activities,
settings and evaluation methods for the fellows.
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
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CORE CURRICULUM
Provide consultation with
referring physicians or services
[PR IV.A.2.a).(1).(a).
Educate diagnostic radiology
residents, and if appropriate,
medical students and other
professional personnel in the
care and management of
patients
[PR IV.A.2.a).(1).(b)]
Follow standards of care for
practicing in a safe environment,
attempt to reduce errors, and
improve patient outcomes
[PR IV.A.2.a).(1).(c)]
Interpret all exams and/or
invasive studies under close,
graded responsibility and
supervision;
[PR IV.A.2.a).(1).(d)]
Assume direct and progressive
responsibility in pediatric
imaging as they advance
through training that culminates
in sufficiently independent
responsibility for clinical decision
making
[PR IV.A.2.a).(1).(e)]
Apply low dose radiation
techniques for both adults and
children
[PR IV.A.2.a).(2).(a)]
Perform all exams and/or
invasive studies under close,
graded responsibility and
supervision
[PR IV.A.2.a).(2).(b)]
List in Bulleted Format the
Learning Activities and
Settings Used to Address the
Core Knowledge Areas for
Patient Care and Procedures
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List in Bulleted Format the
Method(s) Used to Evaluate
Fellow Competency
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12. Briefly describe how fellows will provide consultation with referring physicians or services.
[PR IV.A.2.a).(1).(a)]
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13. Describe how fellows will be educated in and apply low dose radiation techniques in both adults and
children and how they become skilled in preventing and treating complications of contrast
administration. [PR IV.A.2.a).(2).(a), IV.A.2.b).(2)]
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
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Limit to 200 words
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14. Briefly describe how fellows will be provided with direct and progressive responsibility on pediatric
imaging as they advance though the program? [PR IV.A.2.a).(1).(e)]
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Medical Knowledge
1. Describe the activities and settings in which fellows will be given opportunities to develop
knowledge in the following topics and evaluation methods used.
List in Bulleted Format the
Learning Activities and
Settings Used to Address the
CORE CURRICULUM
Core Knowledge Area
Demonstrate a level of expertise  Click here to enter text.
in the knowledge of those areas
appropriate for a radiologist
specialist
[PR IV.A.2.b).(1)]
Demonstrate knowledge in low-  Click here to enter text.
dose radiation techniques for
both adults and children, and
learn how to prevent and/or treat
complications of contrast
administration
[PR IV.A.2.b).(2)]
Prepare and present educational  Click here to enter text.
material for medical students,
graduate medical staff, and
allied health personnel
[PR IV.A.2.b).(3)]
Participate in teaching
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conferences for medical
students, radiology residents,
other residents rotating on the
pediatric radiology service, and
other health professional training
programs
[PR IV.A.2.b).(3).(a.)]
Utilize appropriate imaging as it  Click here to enter text.
is applied to congenital,
developmental, or acquired
diseases of the newborn, infant,
child, and adolescent that are
basic to the practice of
pediatrics
[PR IV.A.2.b).(4)]
Interpret imaging studies of the  Click here to enter text.
pediatric patient with awareness
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
List in Bulleted Format the
Method(s) Used to Evaluate
Fellow Competency
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CORE CURRICULUM
of normal, normal variants, and
typical imaging findings of
pediatric diseases and
congenital malformations
[PR IV.A.2.b).(5)]
List in Bulleted Format the
Learning Activities and
List in Bulleted Format the
Settings Used to Address the Method(s) Used to Evaluate
Core Knowledge Area
Fellow Competency
2. Briefly describe fellow experience utilizing appropriate imaging as it is applied to congenital,
developmental or acquired diseases of the newborn, infant, child, and adolescent. [PR IV.A.2.b).(4)]
Click here to enter text.
3. Briefly describe fellow experience in interpreting imaging studies of the pediatric patient with
awareness of normals, normal variants, and typical imaging findings of pediatric diseases and
congenital malformations. [PR IV.A.2.b).(5)]
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Interpersonal and Communication Skills
Describe the activities and settings in which fellows will be given opportunities to develop knowledge in
the following topics and evaluation methods used.
List in Bulleted Format the
Learning Activities and
Settings Used to Address the
Core Knowledge Area
 Click here to enter text.
CORE CURRICULUM
Communicate effectively with
patients, parents, colleagues,
referring physicians, and other
members of the health care team
concerning imaging and
procedure appropriateness,
informed consent, safety issues,
and the results of imaging tests
or procedures
[PR IV.A.2.d).(1)]
Competence in oral

communication judged through
direct observation
[PR IV.A.2.d).(2)]
Competence in written

communication judged on the
basis of the quality and
timeliness of dictated reports
[PR IV.A.2.d).(3)]
Understanding of techniques that 
improve understanding of ageappropriate behaviors for the
List in Bulleted Format the
Method(s) Used to Evaluate
Fellow Competency
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Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
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CORE CURRICULUM
pediatric patient, and sensitivity
to the needs of parents and
patients
[PR IV.A.2.d).(4)]
Understanding of the cultural,
economic and
intellectual/educational
differences
[PR IV.A.2.d).(5)]
Plan and present conferences
[PR IV.A.2.d).(6)]
List in Bulleted Format the
Learning Activities and
Settings Used to Address the
Core Knowledge Area
List in Bulleted Format the
Method(s) Used to Evaluate
Fellow Competency
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Professionalism
Describe the activities and settings in which fellows will be given opportunities to develop skills in the
following topics.
CORE CURRICULUM
Compassion, integrity and
respect for others
[PR IV.A.2.e).(1)]
Responsiveness to patient needs
[PR IV.A.2.e).(2)]
Respect for patient privacy and
autonomy
[PR IV.A.2.e).(3)]
Accountability to patients,
society, and the profession
[PR IV.A.2.e).(4)]
Sensitivity and responsiveness to
a diverse patient population,
including but not limited to
diversity in gender, age, culture,
race, religion, disabilities, and
sexual orientation
[PR IV.A.2.e).(5)]
Compliance with institutional and
departmental policies, HIPAA,
The Joint Commission, patient
safety, infection control, etc.)
[PR IV.A.2.e).(6)]
List in Bulleted Format the
Learning Activities Used to
Address the Core Knowledge
Area
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List the Corresponding
Setting(s) in Which These
Learning Activities Take Place
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Systems-based Practice
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
Page 9 of 12
Describe the activities and settings in which fellows will be given opportunities to develop skills in the
following topics.
List in Bulleted Format the
Learning Activities Used to
Address the Core Knowledge
Area
 Click here to enter text.
CORE CURRICULUM
Work in interprofessional teams
to enhance patient safety and
improve patient care quality
[PR IV.A.2.f).(1)]
Participate in identifying system 
errors and implementing potential
systems solutions
[PR IV.A.2.f).(2)]
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List the Corresponding
Setting(s) in Which These
Learning Activities Take Place
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Curriculum
1. Explain how training will be provided in each of these pediatric imaging areas (assignment in each
of these areas should include participation in and responsibility for dictation of reports): [PR Int.B.4.]
a) radiography
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b) computed tomography
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c) ultrasonography
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d) vascular interventional techniques
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e) nuclear radiology, including positron emission tomography
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f)
magnetic resonance imaging
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f)
other imaging modalities if applicable
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2. If there are outside rotations, describe the fellows' duties and level of responsibility during each of
the outside assignments. [PR IV.A.3.a).(1)]
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3. Do conferences include:
a) Intradepartmental conferences [PR IV.A.3.d).(1)] ................................................... ☐ YES ☐ NO
If yes, how frequently does this occur? ....................................................................... [Frequency]
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
Page 10 of 12
b) Departmental grand rounds [PR IV.A.3.d).(2)] ........................................................ ☐ YES ☐ NO
If yes, how frequently does this occur? ....................................................................... [Frequency]
c) At least one interdisciplinary conference per week [PR IV.A.3.d).(3)] ..................... ☐ YES ☐ NO
d) Peer-review case conference and/or M&M conference [PR IV.A.3.d).(4)]............... ☐ YES ☐ NO
If yes, how frequently does this occur? ....................................................................... [Frequency]
4. Briefly describe the policy for fellow attendance and participation at local and national meetings.
Indicate whether the program provides reimbursement. [PR IV.A.3.e).-IV.A.3.e).(1)]
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5. Formal didactic sessions
Enter the schedule of planned conferences and lectures. The specific title of lectures/sessions is
requested. Add additional rows as necessary. [PR IV.A.3.f)-IV.A.3.f).(2)]
Reporting Period (Planned 12From:
month period):
Type and Frequency
To:
Title
Fellows’ Scholarly Activities
Describe how fellows will be instructed in the fundamentals of experimental design, performance, and
interpretation of results. [PR IV.B.1.]
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EVALUATION
Fellow Formative Evaluation
1. Will fellow evaluations include at least a quarterly review? [PR V.A.1.b).(3).(a)]........... ☐ YES ☐ NO
2. Will the quarterly review include the following? [PR V.A.1.b).(3).(b)-V.A.1.b).(3).(b).(iv)]
a) review of the faculty’s evaluations of the fellow ...................................................... ☐ YES ☐ NO
b) review of the fellow’s procedure log........................................................................ ☐ YES ☐ NO
c) documentation of compliance with institutional and department policies (e.g. HIPAA, the JC,
patient safety, infection control, etc.] ...................................................................... ☐ YES ☐ NO
d) review of procedural competencies or other simulation learning ............................. ☐ YES ☐ NO
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
Page 11 of 12
Explain any “no” responses.
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Faculty Evaluation
1. Will faculty evaluations include a written confidential evaluation by the fellows? [PR V.B.3.]
.................................................................................................................................... ☐ YES ☐ NO
2. Will faculty receive annual feedback from these evaluations? [PR V.B.3.].................... ☐ YES ☐ NO
Explain any “no” responses.
Pediatric Radiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
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