New Application: Pediatric Endocrinology
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 Endocrinology
©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
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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?
Click here to enter text.
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 Endocrinology
©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
Pediatric Endocrinology
©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
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 Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 11
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 VII.B.2.b)]
Team Members
Diabetes Educator
Nutritionist
Mental Health Personnel
Site #1
☐
☐
☐
Site #2
☐
☐
☐
Site #3
☐
☐
☐
2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
Click here to enter text.
Facilities and Services [PR II.D.; VII.B.]
1. Indicate the availability of the following (for inpatient services, indicate the number of available
beds):
Facility/Service
Space in an ambulatory setting for evaluation
and care of patients
PICU (indicate total number of beds)
Site #1
Site #2
(Yes/No)
(Yes/No)
Choose an item. Choose an item.
Choose an item. Choose an item.
NICU (indicate total number of beds)
Choose an item. Choose an item.
Full support services including, clinical
laboratory, pathology, nutrition, and social
services
Immunohistological Studies
Choose an item. Choose an item.
Comprehensive Diagnostic Imaging (CT,
Isotope Scans, MRI, Others)
Hormone Measurements
Choose an item. Choose an item.
Genetic Testing
Choose an item. Choose an item.
Choose an item. Choose an item.
Choose an item. Choose an item.
Site #3
(Yes/No)
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
Choose an
item.
2. If “NO” is indicated for any of the service/experiences across all sites, explain how the
service/experience is provided below.
Click here to enter text.
Patient Data [PR VII.B.3.]
Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 5 of 11
Provide the following information for the most recent 12-month academic or calendar year. Note the
same timeframe should be used throughout the forms.
Inclusive Dates: FROM: Click here to enter a date.
Total number of admissions to the Pediatric
Endocrinology service
Total number of diabetic patients
Total number of non-diabetic patients
Number of new patients admitted each year (“new”
refers to those who are seen by members of the
Endocrinology service for the first time.)
Average length of stay of patients on the pediatric
Endocrinology service
Total number of consultations by pediatric
Endocrinology.
Number of consultations provided to the NICU
Number of consultations provided to the PICU
Average daily census of patients cared for by the
Pediatric Endocrinologists. Include those on the
Endocrinology service as well as consultations.
Number of patients requiring follow-up care by
Endocrinology service as outpatients during 12month period reported
Total number of diabetic patients
Total number of non-diabetic patients
TO: Click here to enter a date.
Site #1
#
Site #2
#
Site #3
#
#
#
#
#
#
#
#
#
#
Length
Length
Length
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
EDUCATIONAL PROGRAM [PR VIII.]
Ambulatory Pediatric Endocrinology Experience for All Years of Training [PR VIII.A.1]
Add rows as necessary.
Name of Experience
Site/Other Setting Identifier
Planned
Number of
Duration of Sessions
Experience Per Week
(in wks/yr) Per Fellow
Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Estimated
Number of
New
Patients
Per Fellow
Per
Session
Estimated Estimated
Number of
Average
Return
Number
Patients
Teaching
Per Fellow Attendings
Per
Per
Session
Session
Updated 4/2015
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Name of Experience
Site/Other Setting Identifier
Planned
Number of
Duration of Sessions
Experience Per Week
(in wks/yr) Per Fellow
Estimated
Number of
New
Patients
Per Fellow
Per
Session
Estimated Estimated
Number of
Average
Return
Number
Patients
Teaching
Per Fellow Attendings
Per
Per
Session
Session
If the experience is in a private office, provide full details, including name and credentials of supervisor,
numbers and types of patients, degree of fellow responsibility for their care, frequency of attendance at
office, how director monitors the experience and fellow performance.
Click here to enter text.
12-Month Summary - Outpatient/Inpatient Service [PR VIII.A.3]
Summarize how many pediatric patients with the following endocrinology problems were seen in the
ambulatory setting and how many were admitted to or consulted on by the endocrinology service at the
primary site. This should cover the same 12-month period used in previous sections.
Site Name:
Name
Give inclusive dates during
which these admissions/
From: Click here to enter a date.
consultations occurred:
Outpatients
Endocrine Disorders
Disorders of growth
[PR VIII.A.3.a)]
Disorders of anterior pituitary hormone physiology
[PR VIII.A.3.b)]
Disorders of posterior pituitary hormone physiology
[PR VIII.A.3.c)]
Number of
Patients
Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To: Click here to enter a date.
Inpatients
Number on
Endocrine
Number of
Service
Consults
#
#
#
#
#
#
#
#
#
Updated 4/2015
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Outpatients
Endocrine Disorders
Disorders of thyroid hormone physiology (including
secretion and synthesis)
[PR VIII.A.3.d)]
Endocrine neoplasia
[PR VIII.A.3.e)]
Disorders of adrenal gland physiology
[PR VIII.A.3.f)]
Disorders of androgen and estrogen physiology,
including adolescent reproductive endocrinology
[PR VIII.A.3.g)]
Disorders of sexual development
[PR VIII.A.3.h)]
Disorders of parathyroid gland physiology
[PR VIII.A.3.i)]
Disorders of Calcium, Phosphorous, and Vitamin
D)
[PR VIII.A.3.j)]
Disorders of bone physiology
[PR VIII.A.3.k)]
Disorders of fluid and electrolyte balance
[PR VIII.A.3.l)]
Disorders of Carbohydrate Metabolism, including
diabetes mellitus and hypoglycemia
[PR VIII.A.3.m)]
Disorders of nutrition
[PR VIII.A.3.n)]
Obesity including obesity related endocrine
disorders (e.g. polycystic ovarian syndrome,
impaired glucose tolerance, metabolic syndrome
and type 2 diabetes)
[PR VIII.A.3.o)]
Number of
Patients
Inpatients
Number on
Endocrine
Number of
Service
Consults
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
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List of Diagnoses
List 150 CONSECUTIVE patient encounters (inpatient and outpatient excluding diabetes) to the
Pediatric Endocrinology service. 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 of the first patient encounter on the list and end with the date of the 150th
patient encounter, (e.g., July 1, 2014 through October 20, 2014). Submit a separate list for each site
that provides required rotations. Add tables as necessary.
Site Name:
Give inclusive dates during
which these encounters
occurred:
From: Click here to enter a date. To: Click here to enter a date.
Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 8 of 11
Patient ID
Number
Age
Endocrinology Diagnosis
(may include secondary diagnosis if relevant)
Inpatient Experiences
What responsibilities will the fellows have for inpatients and how and by whom will they be
supervised when assigned to inpatient services? [PR VIII.A.1]
Click here to enter text.
Outpatient Experiences
1. Describe the degree of responsibility the fellows will have for required outpatient care, including
longitudinal care. [PR VIII.A.2]
Click here to enter text.
2. Describe how and by whom the fellows will be supervised in the outpatient setting. [PR VI.D]
Click here to enter text.
Core Curriculum
Identify the learning activities (clinical experience, conference series, journal club, etc.) and training
sites (Site #) which will be used to address the required core knowledge area.
Endocrinology Related
Systems
Disorders of growth
List the Corresponding
List the Learning Activities Setting in Which These
Used to Address the Core Learning Activities Take
Knowledge/Skills
Place
Click here to enter text.
Click here to enter text.
Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Year(s) of
Training
#
Updated 4/2015
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Endocrinology Related
Systems
[PR VIII.A.3.a)]
Disorders of anterior pituitary
hormone physiology
[PR VIII.A.3.b)]
Disorders of posterior
pituitary hormone physiology
[PR VIII.A.3.c)]
Disorders of thyroid hormone
physiology
[PR VIII.A.3.d)]
Endocrine neoplasia
[PR VIII.A.3.e)]
Disorders of adrenal gland
physiology
[PR VIII.A.3.f)]
Disorders of androgen and
estrogen physiology,
including adolescent
reproductive endocrinology
[PR VIII.A.3.g)]
Disorders of sexual
differentiation and
development
[PR VIII.A.3.h)]
Disorders of parathyroid
gland physiology
[PR VIII.A.3.i)]
Disorders of calcium,
phosphorus, and vitamin D
[PR VIII.A.3.j)]
Disorders of bone physiology
[PR VIII.A.3.k)]
Disorders of fluid and
electrolyte balance
[PR VIII.A.3.l)]
Disorders of carbohydrate
metabolism, including
diabetes mellitus and
hypoglycemia
[PR VIII.A.3.m)]
Disorders of nutrition
[PR VIII.A.3.n)]
Obesity including obesity
related endocrine disorders
[PR VIII.A.3.o)]
Laboratory techniques for
measurement of hormones in
List the Corresponding
List the Learning Activities Setting in Which These
Used to Address the Core Learning Activities Take
Knowledge/Skills
Place
Year(s) of
Training
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Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 10 of 11
Endocrinology Related
Systems
body fluids
[PR VIII.B.1]
Interpretation of endocrine
stimulation and suppression
tests
[PR VIII.B.1.b)]
Informed selection of most
appropriate diagnostic
imaging for a given endocrine
problem
[PR VIII.B.1.c)]
Indication, risks and
interpretation of diagnostic
assays
[PR VIII.B.1.c)]
Diabetes education
[PR VIII.A.2]
Hormone replacement
therapy
[PR VIII.A.4]
List the Corresponding
List the Learning Activities Setting in Which These
Used to Address the Core Learning Activities Take
Knowledge/Skills
Place
Year(s) of
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.
Click here to enter text.
Pediatric Endocrinology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
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