THE CCFA VISITING IBD FELLOW PROGRAM 2014-2015 APPLICATION
APPLICATION DUE DATE: JANUARY 13, 2014 BY 5 PM.
PLEASE DO NOT SEND INCOMPLETE APPLICATIONS.
I. Introduction
For 40 years, the Crohn's & Colitis Foundation of America (CCFA) has worked to advance professional
education in the diagnosis, treatment and management of patients with inflammatory bowel disease
(IBD).
The program is being directed by Thomas Ullman, M.D. (Mount Sinai Medical Center) and Corey Siegel,
MD (Dartmouth Hitchcock Medical Center). Members of CCFA’s National Scientific Advisory Committee
and faculty at the IBD Fellowship Center will facilitate the program.
II. Program Description
The Crohn's & Colitis Foundation of America (CCFA) National Visiting IBD Fellow Program is designed
for GI fellows who want to gain focused experience in inflammatory bowel disease.
The overall goal of the program is to offer GI fellows the opportunity to accelerate their career
development by participating in the clinical operations of a leading IBD Center. A formal curriculum for
this program has been designed to meet educational and credential goals and to provide a
comprehensive training program.
The Fellow will spend one month in the city of one of these centers, during which time they will be
involved, as an observer, in the clinical operations of the inflammatory bowel disease center, participate
in rounds and conferences and hopefully, enjoy the camaraderie of the other Fellows in those programs.
The IBD Centers vary by each program year. The following centers are among the past participating
facilities: Cedars-Sinai Medical Center, Cleveland Clinic Foundation, Mayo Clinic, Mount Sinai Medical
Center, University of Chicago, and the University of North Carolina. A list of participating sites are
included below. Please note that sites may change; a final list of participating centers will be sent to all
applicants prior to the application review period.
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III. Applicant Eligibility & Requirements
The ideal candidates are GI fellows who express an interest in learning more about inflammatory bowel
disease (irrespective of their plans to be in private practice or stay in academics), and who are at centers
that are distant from IBD referral programs.
At the time of application, the applicant must:
1- Hold an M.D. or equivalent degree.
2-
Be employed by an institution (public non-profit, private non-profit, or government) engaged in
health care and/or health related research within the United States. Eligibility is not restricted by
citizenship. However, proof of legal work status is required.
3- Military Personnel
a. Must have full written approval to participate in the program before appyling from
their medical director and any military oversight personnel.
b. As part of the application, you must submit a detailed letter stating that if accepted into
the program your supervisor and department are able to accept the stipend provided by
CCFA to off-set the participants salary. See template letter provided.
c. If accepted CCFA will provide a proffer letter.
V. Budget Policies and Restrictions
No indirect costs are allowed.
CCFA will provide a post-program stipend to cover expenses at the completion and return of ALL required
documentation.
Program participants will be reimbursed for usual and reasonable expenses related to travel, meetings
conducted on behalf or in connection with executing the mission of the program and the organization.
Documentation/Substantiation Requirements:
Expenses are required to meet four conditions:
 Expenses must be for a legitimate business purpose
 It must be substantiated with receipts
If accepted a Travel and expense policy will be provided.
**Please be advised that CCFA reserves the right to determine which items are reimbursable. **
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VI. Reporting Requirements
At the end of the program Fellows must submit:
 Receipts for CCFA related expenses.
o Expenses without an original receipt will not be reimbursed.
 Daily activity report which is signed by faculty members.
 Pre and Post- evaluation survey
o The surveys and the activity report will be provided by CCFA.
 Power Point Presentation Give an overview of IBD and what was learned during the rotation.
 After successful completion of the program, your stipend will be issued.
VII. Application Scoring and Notification Procedure
The application must be completed and sent to CCFA along with the following documents:
 A current CV – should include the following information:
o Education (beginning with entry into college)
o Experience (all positions held post-doctoral)
o Degree……….year conferred……………….
o Training in IBD (type of training, institution, dates & director)
o Specialty or subspecialty board certification(s) held
o All publications
o Academic professional honors (including all scholarships, traineeships, fellowships, with
data and sources)
o Membership in professional societies within the past 10 years
 A recommendation letter from the Program Director explaining why you are a good candidate for
this Fellowship.

Military Personnel (ONLY)
o Military personnel please provide additional documentation requested above on page 2.
Please email or mail application (including documents) to:
CCFA National Visiting IBD Fellow Program 2014-2015
Attention: Ebony Brown
Crohn's & Colitis Foundation of America
733 Third Avenue, Suite 510
New York, NY 10017
Email: ebrown@ccfa.org
Phone: 646-943-7412
NO FAXES!
PLEASE DO NOT SEND INCOMPLETE APPLICATIONS.
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The Visiting IBD Fellow program is funding dependent and applications are accepted on a rolling basis.
Once CCFA secures funding for the program a notice will be sent to all applicants outlining the final
deadline for material submission. Applicants will also receive a notice as to when completed applications
will be reviewed and scored. Incomplete applications will not be scored.
The Visiting IBD Fellow Scoring Committee will be composed of at least three to five members of the
CCFA’s Professional Education Committee. All applications will be scored in three categories:
1.
Availability of IBD training at their home institution
2.
Objective criteria which is includes but is not limited to the fellows educational and research
accomplishments, and
3.
The candidate’s responses to application questions and their interest in the program.
The candidates with the highest score will be selected for the program and immediately notified via email.
Once all selected applicants have confirmed their participation CCFA will notify all other candidates and
designated alternates about their application status.
THE CCFA VISITING IBD FELLOW PROGRAM 2014-2015
Application – Part I
1. Please complete the following questions.
First Name
Middle Name:
Last Name:
Gender:
Home Address:
Street:
Apt # ( if applicable)
City:
State
Zip
D.O.B:
Institution:
Address:
City:
State:
Zip:
Email:
Business Telephone:
Fax:
Home Phone:
Cell Phone:
Current Appointment:
Degree:
Title:
2. What is the complete name and address of your current fellowship?
____________________________________________________________________________
____________________________________________________________________________
3. How many fellows does your institution support each year?
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4. Is you program ACGME approved? _____Yes _____ No
5. Please list states in which you are licensed to practice.
________________________________________________________________________
________________________________________________________________________
6. Are you a member of the Crohn's & Colitis Foundation of America (CCFA?)
_____Yes
______No
_______Send Me More Information
7. If selected to participate, would you be willing to share your contact information with other Fellows in
the program?
_____Yes
______No
8. Where did you hear about this Visiting IBD Fellow Program?
 Advances in IBD Conference
CCFA Website
 Fellowship Brochure
 Gastroenterology
 IBD Journal
 CCFA Chapter
 GI department at Home institution
 Other (Please Specify :_______________________)
9. What is your primary reason for committing to the Visiting IBD Fellow program?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
10. What do you hope to gain from this program?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
11. What are your career plans?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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12. These are the centers that participated in Phase III of the program. Additional facilities may be
added. Below, please list your first, second, and third choices, AS WELL AS the months that you are
available to travel.
Cedars-Sinai Medical Center
GI Department
8700 Beverly Blvd. Rm 1165W
Los Angeles CA 90048
*PEDIATRIC ONLY*
Cleveland Clinic Foundation
GI Department
9500 Euclid Avenue. 1A30
Cleveland OH 44195
*ADULT ONLY*
Massachusetts General Hospital
GI Division
100 Charles River Plaza, 9th Floor
Cambridge Street
Boston, MA 02114
*ADULT ONLY*
Mayo Clinic
GI Department
200 First Street, SW
Rochester, MN 55905
*ADULT ONLY*
Mount Sinai Medical Center
GI Department
One Gustave L. Levy Place, Box 1069
New York, NY 10029
*ADULT ONLY*
University of Chicago
GI Department
5841 S. Maryland Ave. MC 4080
Chicago, IL 60637
*ADULT or PEDIATRIC*
University of North Carolina
Division of Gastroenterology and Hepatology
CB# 7080 Room 1143 Bioinformatics
Chapel Hill, NC 27599
*ADULT ONLY*
University of Pittsburgh
Division of GI, Hepatology & Nutrition
CB#7032, Room 7200 MBRB
103 Mason Farm Road
Chapel Hill, NC 27599-7032
*ADULT ONLY*
University of California at San Francisco
GI Division
513 Parnassus Avenue, S-357
San Francisco, CA 94143
*ADULT ONLY*
1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________
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MONTHS AVAILABLE: _______________________________________
(The month of May is not available due to Digestive Disease Week)
****FACILITY PREFERENCES WILL BE CONSIDERED BUT ARE NOT GUARANTEED. ****
Applicant Home Institution – Part II
Program Director(s) / Mentor(s):
Name: ______________________________Degree(s) _______________________________
Office Address: _______________________________________________________________
City: State: Zip Code: __________________________________________________________
Office Number: (
)_______________________Fax:_________________________________
Name: ______________________________Degree(s) _______________________________
Office Address: _______________________________________________________________
City: State: Zip Code: __________________________________________________________
Office Number: (
)_______________________Fax:_________________________________
Required Signatures – Part III
THIS STATEMENT MUST BE SIGNED BY THE APPLICANT
I am familiar with the regulations, policies and objectives of the Crohn’s & Colitis Foundation of America,
concerning this application for the CCFA National Visiting IBD Fellow Program.
In the event this application is approved, I agree to fully comply with these regulations during the entire
period of the program and am aware of the reporting requirements I must adhere to.
Signature__________________________________________Date___________________________
THIS STATEMENT IS TO BE SIGNED BY THE DEPARTMENT DIRECTOR
I am familiar with this application for the National Visiting IBD Fellow Program of the Crohn’s & Colitis
Foundation of America, Inc., and with the regulations, policies, and objectives of the Visiting IBD Fellow
Program.
Signature__________________________________________Date__________________________
Name:___________________________________________________________________________
Department:_______________________________________________________________________
Institution:_________________________________________________________________________
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