(Part 2)
Fellowship
Name/Program #:
Detail the arrangements for funding of the resident stipend(s) and benefits and specifically identify those facilities that will be providing such support. Note whether the support will be in addition to current funding or if it will reduce positions in current programs. Attach copies of funding commitment letters.
Name of Program Director:
Title of Program Director:
Faculty appointment date:
Program Director appointment date:
TMB license number:
Board certification:
Other certification:
Expiration:
Date:
Date :
Name of Associate Program Director (if applicable):
Title of Associate Program Director:
Name of Program Coordinator:
Contact information:
Name
Add extra lines as needed.
Title
Board
Certification
Appropriate
Educational
Qualifications
UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011 Page 1

Describe the curriculum for the program.
Explain the process by which subspecialty (fellowship) postgraduate residents are selected:
Delineate the duties and responsibilities required of subspecialty (fellowship) postgraduate residents in the fellowship:
List the scholarly activity to be required of subspecialty postgraduate residents:
What type of supervision is to be provided for subspecialty (fellowship) postgraduate residents?
Are the program director and supervising physicians required to hold a Texas license or faculty temporary license issued by the board?
Explain the methods for evaluation of subspecialty (fellowship) postgraduate residents by the fellowship:
If the fellowship is over one year in length, explain the progressive nature, including, but not limited to, the progressively greater responsibility of the subspecialty (fellowship) postgraduate residents throughout the course of the fellowship:
UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011 Page 2

Number of applications and number of positions offered for the past five years:
Year
Applications
Received
Applicants
Interviewed Positions Offered
List fellows who have entered and completed the program since original approval (up to 5 years), describing their current professional practice and how they are using the training received during this fellowship.
Name
Month/
Year
Starting
Program
Prior GME
Training
(Institution)
*
IMG
(Yes/No)
Month/Year
Completed
Program
Application of this
Fellowship in
Current Practice
*List name(s) of institution(s) where prior GME Training was received.
List the scholarly activity of most recent graduates:
Describe the Duty Hour expectations of the program:
Do fellows take pager call from home? If so, describe the frequency and the typical volume of pages per night.
Do fellows take in-house overnight call? If so, describe the frequency and how Duty Hour limits are maintained.
UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011 Page 3

Fellowship
Name/Program #:
If the documents requested are in the program manual, it is not necessary to duplicate the documents in the attachment section. Please indicate the page number where this information may be found in the manual.
Attachment Checklist
Attached to this document
This document is not available or not applicable
1.
Funding commitment letters
2.
Program Director CV
3.
Competency-based Goals &
Objectives by Rotation
4.
Block Schedule
5.
Evaluation Forms
6.
Program Duty Hour Policy
7.
Program requirements from oversight agency (non-ACGME programs)
Program Director: ______________________________________________________________
Date
DMO: _______________________________________________________________________
Date
Division Head: _________________________________________________________________
Date
Chairman: ____________________________________________________________________
Date
Recommendation
Status
Internal Review (approximate date)
Approval
IREC
GMEC
Oversight agency (as applicable):

TMB

Other:
Date Comments
UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011 Page 4

All electronic files of the attachments should be clearly labeled with the corresponding attachment number
1-7 at the beginning of the file name. (ie. 3-GO-MHH.*; 4-blocksched.*)
1.
Funding commitment letters
2.
Program Director CV
3.
Competency-based Goals & Objectives by Rotation

Educational objectives should be constructed to show a.
what the learner is to be able demonstrate at the conclusion of the learning exercise, b.
under what conditions the learner should be able to demonstrate same, and c.
what criteria will be used to judge that performance.

Additionally, the each objective should state necessary pre-requisites and they should be appropriately sequenced.

An important part of writing appropriate objectives is the use of ‘action verbs’.
“Understand” does not meet the criteria for an appropriate objective.
4.
Block Schedule
Three block schedule templates have been provided below. Please use one of these formats.
Rotation
1
Location
Rotation
Location
2
2 months
3 4
2 months
5 6
2 months
7 8
2 months
9 10 11
2 months
12
2 months
Rotation
Location
3 months 3 months 3 months 3 months
5.
Evaluation Forms
Attach evaluation forms for:

Evaluation of Fellow by Faculty/Program Director

Evaluation of Program by Fellow

Evaluation of Faculty/Program Director by Fellow

Any additional evaluation forms
6.
Program Duty Hour Policy
7.
Program requirements from oversight agency (non-ACGME programs)
UTHSC-H Renewal Application for TMB Approved Fellowship – October 2011 Page 5