Headache Medicine
Program Accreditation Application
Appendices A-J Templates
Please note:
1. All templates and forms provided within this document must be used.
2. Only provide requested information.
Last Revised: March 2015
©2015
Appendix A: Institution Letter
The institution letter referenced in the Program Information Form (PIF) Section 2 is a confirmation of
participation letter from the appropriate institution official of each sponsoring, primary, and participating
institution of your program. Submitted letters must utilize the template language below for Appendix A. Do NOT
submit the full affiliation or letter of agreement. The letter must include the signature of the appropriate official.
Institution definitions: 1) the sponsoring institution, which assumes ultimate responsibility for the program and
is required of all programs, 2) the primary institution, which is the primary clinical training site and may or may
not be the sponsoring institution, and 3) the participating institution, which provides required experience that
cannot be obtained at the primary or sponsoring institutions. The sponsoring institution letter must be signed by
the ACGME/RCPSC-accredited sponsoring institution’s designated institution official.
The following is the template language for the letter:
Date
John Kohring, Executive Director
United Council for Neurologic Subspecialties
201 Chicago Avenue
Minneapolis, MN 55415
Dear Mr. Kohring,
This letter serves as the [Sponsoring/Primary/Participating] Institution Letter that accompanies the accreditation
application for the [Program Name].
The [institution name] is committed to the training and committed to providing the appropriate education. [List
specific educational activities that will be undertaken, supported, and supervised at the institution].
Sincerely,
[Name]
[Designated Institution Official/Department Chair/Medical Director]
[Institution Name]
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 2 of 14
2015
Appendix B: Curriculum Vitae (CV)
Use the CV template provided below for Appendix B for the entire program faculty. This must include the
program director and all faculty listed in the faculty tables in PIF Section 4. CVs MUST be submitted using this
template. NIH biosketches and complete CVs will not be accepted.
CURRICULUM VITAE
Name:
Degree(s):
Medical School:
Residency:
Fellowship:
Certification(s):
ABPN/RCPSC-Neurology
ABPN/RCPSC-Child Neurology
ABMS/RCPSC-Other (specify):
UCNS (specify):
Other (specify):
List any equivalent training here:
Credentials:
Title:
Date of Graduation:
Date of Graduation:
Date of Graduation:
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Date:
Date:
Date:
Date:
Date:
Date:
Active state licensure(s):
Date(s):
Current academic positions:
Date assumed this position:
Current hospital appointments:
Date of appointments:
Full time
Part time
If part time:
How many weeks per year:
How many hours per week:
Describe any teaching/curricular experience. Also include any administrative experience/appointments,
including the location and dates of appointment.
List the most recent publications in journals (maximum 10 articles). Do not include presentations, abstracts, and
those ‘in preparation’ or ‘submitted.’
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 3 of 14
2015
Appendix C: Graphic Display of the Curriculum
Using ONE of the three templates provided below for Appendix C, describe the typical curriculum for fellows. If more than one curricular option
is offered, please copy the template and include all options available within the program, ensuring that each option is clearly identified.
Option 1 – Block Rotations in Months
Using the template provided below for Appendix C, describe in block form the typical curriculum for fellows by months including the institution
(#1, 2, 3, 4) as listed in PIF Section 2. If you require an extended table, please e-mail your request to applications@ucns.org.
Curricular components may be offered in blocks or longitudinally. An example of the latter is a regularly scheduled clinic attended over a period
of time while assigned to other rotations. Those components offered in block assignments each year should be recorded in the block template.
Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. You should not include
conferences, lectures, or other didactic experiences in the longitudinal template.
Year 1
July
BLOCK ROTATIONS
August
September October
November December January
February
March
April
May
June
LONGITUDINAL EXPERIENCES
Type of experience
Time commitment per week
Number of weeks per
year
Amount of time in months (e.g., 40 half days=1 month)
Year 2
Not applicable
July
BLOCK ROTATIONS
August
September October
November December January
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
February
March
Page 4 of 14
2015
April
May
June
LONGITUDINAL EXPERIENCES
Type of experience
Time commitment per week
Number of weeks per
year
Amount of time in months (e.g., 40 half days=1 month)
Year 3
Not applicable
July
BLOCK ROTATIONS
August
September October
November December January
February
March
April
May
June
LONGITUDINAL EXPERIENCES
Type of experience
Time commitment per week
Number of weeks per
year
Amount of time in months (e.g., 40 half days=1
month)
Option 2 – Block Rotations in Four-Week Stints
Using the template provided below for Appendix C, describe in block form the typical curriculum for fellows by four-week stints including the
institution (#1, 2, 3, 4) as listed in PIF Section 2. If you require an extended table, please e-mail your request to applications@ucns.org.
Curricular components may be offered in blocks or longitudinally. An example of the latter is a regularly scheduled clinic attended over a period
of time while assigned to other rotations. Those components offered in block assignments each year should be recorded in the block template.
Those clinical experiences offered longitudinally should be recorded separately in the longitudinal templates by year. You should not include
conferences, lectures, or other didactic experiences in the longitudinal template.
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 5 of 14
2015
Year 1
1
BLOCK ROTATIONS
2
3
4
5
6
7
8
9
10
11
12
13
LONGITUDINAL EXPERIENCES
Type of experience
Time commitment per week
Number of weeks per
year
4
7
Amount of time in months (e.g., 40 half days=1 month)
Year 2
Not applicable
1
BLOCK ROTATIONS
2
3
5
6
8
9
10
11
12
13
LONGITUDINAL EXPERIENCES
Type of experience
Time commitment per week
Number of weeks per
year
4
7
Amount of time in months (e.g., 40 half days=1 month)
Year 3
Not applicable
1
BLOCK ROTATIONS
2
3
5
6
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
8
9
10
Page 6 of 14
2015
11
12
13
LONGITUDINAL EXPERIENCES
Type of experience
Time commitment per week
Number of weeks per
year
Amount of time in months (e.g., 40 half days=1
month)
Option 3 - Other
If your program does not use block rotations, please describe how your curriculum is structured below. Illustrating the structure graphically is
encouraged. Programs choosing this option should be aware that using a non-provided template may cause delay in the application review as it
may lead to additional reviewer questions.
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 7 of 14
2015
Appendix D: Goals and Objectives
Using the template provided below, identify and describe all rotations in which fellows participate. THE ACGME COMPETENCY/GLOBAL LEARNING
OBJECTIVES, A SAMPLE COMPLETED TABLE, AND ADDITIONAL REFERENCE MATERIALS are available on the UCNS website.
For EACH rotation:
1) name the rotation,
2) describe the rotation (block vs. longitudinal, description of activities, etc.),
3) list the specific learning objectives (see the Goals and Objectives Example, which is available on the UCNS website),
4) link each specific learning objective to corresponding ACGME competency/global learning objective(s) using the numbers from the global objectives
table available on the UCNS website (e.g., A.1. for the first objective in the patient care core competency),
5) identify the objective type(s) (knowledge, skills, and attitudes and behaviors)*,
6) identify the assessment type(s) (formative or summative)*, and
7) identify the assessment method(s) (multiple choice questions, test, essay, oral exam, NEX, etc.)*.
*For assistance in writing objectives and determining the objective type(s) and assessment type(s) and method(s), reference the Guide to Writing Goals &
Learning Objectives Linked to Assessments: Curricular Alignment, which is available on the UCNS website.
COPY AND PASTE THE FOLLOWING FOR EACH PROGRAM ROTATION.
Rotation Name:
Rotation Description:
Specific Learning Objectives
By the conclusion of the program, the fellow must:
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
ACGME
Competency
Objective
Type(s)
Page 8 of 14
2015
Type(s)
Assessment
Method(s)
Appendix E: Formal Didactics
Using the template provided below for Appendix E, list the schedule all didactics in which fellows participate.
Indicate which are mandatory and who attends them. The curricular components listed must ensure that all
required didactic components that are listed in the program requirements are included in the program’s curriculum.
Didactic Course/Lecture/Conference Title and/or Description
State the course/lecture/conference title and, if the title does not
clearly indicate to what portion of the didactic curriculum it relates,
please describe how the course meets the program requirements.
Offered Daily
Mandatory
Course?
(Yes/No)
Who attends?
(fellows only; residents and
fellows; residents, fellows,
and medical students, etc.)
Offered Weekly
Offered Monthly
Offered Quarterly
Offered Annually
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 9 of 14
2015
Appendix F: Clinical Components
Using the template provided below for Appendix F, indicate which clinical experiences are included in the program.
Experiences included in the program:
Inpatient ward service
Inpatient consultation service
Outpatient consultation clinic
Outpatient continuity clinic
Emergency room consultation
Nursing home consultation
Nursing home continuity care
Home care
Overnight call
Other (describe):
Other (describe):
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
Page 10 of 14
2015
Appendix G: Duty Hours Compliance
Please submit a copy of the policy on duty hours and a call schedule to complete Appendix G.
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 11 of 14
2015
Appendix H: Fellow Meeting Attendance, Research Projects, Publications, and Scholarly Activity
Using the template provided below, list the meeting attendance, research projects, publications, and scholarly
activity by fellows for the past three years.
Meeting attendance
Provide a list of meetings that program fellows have attended over the past three years, showing the fellows by
name.
Fellow
Meeting
Time period
(over the last three years)
Research projects
List the research projects by program fellows during the past three years.
Fellow
Research project
Publications
List the publications by program fellows during the past three years.
Fellow
Publication
Time period
(Over the last three years)
Time period
(Over the last three years)
Scholarly Activity
List the number of scholarly activities by fellows during the past three years.
Based on Academic Year Ending
Number of nationally peer-reviewed published articles
authored or co-authored by fellows during the year
Number of fellow presentations at regional or national
meetings in the year
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
June 30,
June 30,
June 30,
Page 12 of 14
2015
Appendix I: Evaluation Form Samples
Please provide a sample of a final evaluation used to evaluate fellows completing the program for Appendix I. This
final evaluation should demonstrate the fellow’s competence to practice as an independent practitioner in the
subspecialty.
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 13 of 14
2015
Appendix J: Headache Medicine Specific
Please respond to the following:
1. Please indicate if the following resources are available to the program:
a. A headache center (clinic) designed specifically for the management of headache patients.
Yes
No
b. Adequate allied health staff and other support personnel.
Yes
No
c. A minimum of 200 patients per fellow per year for evaluation under faculty supervision. This minimum
must include a variety of chronic, acute, outpatient, and inpatient headache patients.
Yes
No
d. Access to consultation from all other disciplines involved in Headache Medicine.
Yes
No
2. The fellow must have adequate resources and infrastructure support. Indicate that the following are
available to the fellow:
a. Laboratory facilities
Yes
No
b. Imaging facilities
Yes
No
c. Psychiatric consultation
Yes
No
d. Psychological services
Yes
No
e. Medical record keeping
Yes
No
f.
Procedural pain clinics
Yes
No
g. Dental and/or maxillofacial clinics
Yes
No
h. Infusion therapies
Yes
No
UCNS Program Accreditation Application Appendices A-J Templates
Headache Medicine
Page 14 of 14
2015