Neurosurgery Research and Education Foundation (NREF)
5550 Meadowbrook Drive
Rolling Meadows, IL 60008
Phone: 847.378.0500
Fax: 847.378.0600
Email: NREF@AANS.org
www.nref.org
FELLOWSHIP GRANT GUIDELINES: 2015-2016 funding year
Includes the following fellowship programs:
 General Neurosurgery
 Neurocritical Care
 Neurosurgical Oncology
 Cerebrovascular Neurosurgery
 Endovascular Neurosurgery
 Pediatric Neurosurgery
 Peripheral Nerve Surgery
 Spine Surgery
 Stereotactic and Functional Neurosurgery
Application Package – Table of Contents

Administrative Policies and Procedures
Page 2

Program Information
Page 3-4

Instructions - Completion of Application
Pages 5-6

Fellowship Grant Guidelines
Pages 7-8
APPLICATION DEADLINE – Midnight, Tuesday, August 1, 2014
ADMINISTRATIVE POLICIES AND PROCEDURES FOR FELLOWSHIP GRANT
Page 1
I.
GENERAL INFORMATION
A.
Objective - The objective of the fellowship grant is to fund post-residency clinical fellowships in the specialty of
neurosurgery. Fellowship funding is offered, through this application, in the neurosurgical sub-specialty areas of
general neurosurgery, neurocritical care, neurosurgical oncology, cerebrovascular, neurosurgery, endovascular
neurosurgery, pediatric neurosurgery, peripheral nerve surgery, spine surgery, and stereotactic and functional
neurosurgery.
B.
Eligibility Criteria - See page 3 for more information.
C.
Deadline for Application - Midnight, Tuesday, August 1, 2014. This is the date applications are due, not the
postmark date.
D.
Period of Fellowship - One year, beginning July 1, 2015 through June 30, 2016
E.
Amount of Fellowship Grant - Fully funded fellowship grants will be awarded in the amount of $75,000 for spine
surgery and $50,000 for all others. Depending on available support, grants may be awarded in lesser amounts.
Institutions are limited to one (1) fellowship grant application per category per year with the exception of spine where
one adult spine fellowship application and one pediatric spine fellowship application will be accepted. The grant is
intended to cover the salary and benefits for the fellow first and some, if not all, related non-salary direct costs.
Fellowship funds may not be used for indirect fellowship costs.
F.
Items Required 1. Applicant must submit a completed, current version of this application.
2. Original application (with signatures in blue ink) and (2) copies must arrive in the NREF office by the
midnight, Tuesday, August 1, 2014 deadline.
 Electronic submission of the application will be accepted, in addition to the traditional hard copy
format. If submitting an electronic copy of the application, please submit all documents in one merged
PDF file to nref@aans.org.
 Please note that all applicants must send the hard copy signature page to the AANS – NREF Executive
Offices.
4. Letter of Accreditation from ACGME.
5. Certificate letter demonstrating CAST accreditation for neurological surgery fellowship (if applicable)
 In the event an Applicant has applied for CAST accreditation but has not yet received CAST
accreditation, please submit a copy of the CAST accreditation request with the application.
6. IRS Non-Profit Status Determination letter.
G.
Submission Instructions - Remove fellowship grant guidelines and instruction pages (1-7) before saving application
and making copies for submission. Submissions failing to follow the guidelines or instructions may not be
considered.
Completed applications should be sent c/o:
Sourma Khoury, Development Coordinator
Neurosurgery Research and Education Foundation (NREF)
5550 Meadowbrook Drive
Rolling Meadows, IL 60008
Phone: 847.378.0500 / Email: nref@aans.org
Please visit the NREF website – www.nref.org - for program overview and frequentlty asked questions. For
additional information please contact Sourma Khoury at sak@aans.org.
II.
PROGRAM INFORMATION
Page 2
A.
Eligibility
1.
Any academic institution or group practice with an established neurosurgery residency program that
qualifies as a non-profit, charitable entity may apply. A for-profit entity is not eligible unless affiliated
with a non-profit entity. Institutions must have an ACGME accredited Residency Program or if the
institution does not have an ACGME accredited program, the residency program should still satisfy the
ACGME Program Requirements for Graduate Medical Education in Neurological Surgery
(www.acgme.org), effective July 1, 2009.
Fellowship programs should be accredited by the Committee on Accreditation of Subspecialty Training
(CAST) through the Society of Neurological Surgeons (SNS); if the fellowship program is not CAST
accredited, it should demonstrated theat it satisfies the Program Requirements for Fellowship Education in
the neurological sub-specialty the fellowship is in, which include but are not limited to:
a.
b.
c.
d.
e.
f.
g.
h.
Advanced Training in NeuroCritical Care; Neurological Surgery
Cerebrovascular Neurosurgery
Endovascular Neurosurgery
Neurologic Surgery of the Spine
Neurosurgical Oncology, Clinical Curriculum for Subspecialty Training in Neurosurgical
Oncology
Pediatric Neurologic Surgery
Peripheral Nerve
Stereotactic and Fuctional Neurosurgery, Curriculum for Subspecialty/Fellowship Training in
Stereotactic and Functional Neurosurgery published by the Society of Neurological Surgeons
(www.societyns.org/fellowships). This program does not include funding for individual fellows
seeking support for their training; these grants are instead intended for the institutions which
provide the fellowships.
2.
Institutions may apply for one (1) fellowship per category per year with the exception of spine where one
adult spine fellowship application and one pediatric spine fellowship application will be accepted. The
categories include General Neurosurgery, Neurocritical Care, Neurosurgical Oncology, Cerebrovascular
Neurosurgery, Endovascular Neurosurgery, Pediatric Neurosurgery, Peripheral Nerve Surgery, Spine
Surgery, and Stereotactic and Functional Neurosurgery.
3.
Institution should demonstrate either of the following:
a.
Accreditation Council for Graduate Medical Education (ACGME) certification for neurosurgery
residency program; OR
b.
If the institution does not have an ACGME accredited neurosurgery residency program, the
program should still satisfy the ACGME Program Requirements for Graduate Medical Education
in Neurological Surgery (www.acgme.org), effective July 1, 2009.
4.
Institution must provide proof of qualification as a non-profit, charitable entity (IRS determination letter).
5.
Certificate letter indicating CAST accreditation for neurologic surgery fellowship (if applicable).
a.
In the event the institution has applied for CAST accreditation but has not yet received CAST
accreditation, please submit a copy of the CAST accreditation request with the application.
b.
In the event the institution is not CAST accredited and has not applied for CAST accreditation,
the institution should nonetheless demonstrate that it satisfies the CAST Program
Requirements in the applicable Neurosurgical sub-specialty.
B. Fellowship Funding Overlap/Duplicate Funding
Funding for a fellowship awarded by the NREF through this post-residency, clinical fellowship grant program cannot be
duplicated by any other outside funding source. If the institution receives funding from another source for a fellowship
awarded by NREF through this program, the institution’s Fellowship Program Director must notify the NREF
immediately and return the fellowship funding. Notification must be sent to Sourma Khoury by email at sak@aans.org
C. Application Procedure
Page 3
1.
Please confirm applicant status regarding ACGME accreditation.
2.
Complete an application for each fellowship category for which funding is requested.
3.
Submission instructions

Applicant must submit a completed, current version of this application.

Original application (with signatures in blue ink) and (2) copies must arrive in the NREF office by
the midnight, Tuesday, August 1, 2014 deadline.
Electronic submission of the application will be accepted, in addition to the traditional hard copy
format. If submitting an electronic copy of the application, please submit all documents in one
merged PDF file to nref@aans.org.
Please note that all applicants must send the hard copy signature page to the AANS – NREF
Executive Offices.


4. Letter of Accreditation from ACGME.
5. Certificate letter demonstrating CAST accreditation for neurological surgery fellowship (if applicable)
 In the event an Applicant has applied for CAST accreditation but has not yet received CAST
accreditation, please submit a copy of the CAST accreditation request with the application.
6. IRS Non-Profit Status Determination letter.
D. Notification of Award
The foundation expects to notify each applicant by letter on or before April 1, 2015; however, public
announcement will be contingent upon receipt of written confirmation from applicants. The foundation reserves the
right, in its sole discretion, to extend the date for it to provide notification of awards.
.
Page 4
III.
INSTRUCTIONS FOR COMPLETING FELLOWSHIP GRANT APPLICATION
A.
B.
Page 1A, 2A and 3A of application
1.
Indicate the category for which you are applying. An institution may apply for one (1) fellowship per
category with the exception of spine where one adult spine fellowship application and one pediatric
fellowship application will be accepted.
2.
Signatures are required from the department chairman and fellowship program director. Please use blue ink
for all required signatures; no per signatures are permitted.
Page 4B - Table of Contents
When you have completed your application, please complete the Table of Contents by sequentially
numbering the pages on the bottom center of each page.
C.
Pages 5C and 6C - Fellowship Selection Process & Completion Requirements
1.
Complete information requested on fellow.
2.
Complete information requested on the applicant institution’s fellowship program.
D. Page 7D – Complete Fellowship Program Overview
E. Page 8E - Complete Summary of Program Requirements
F.
Pages 9F and 10F pages - Fellowship Program Faculty/Biographical Sketch
Demonstrate that the faculty is properly trained, properly accredited, and sufficient in size to provide adequate
instruction and supervision of fellows. Include information to show that the faculty members have the necessary
expertise and competence in clinical care, are in good standing and have appointments at the participating
institution.
1.
List each faculty member, including their qualifications and role in the program. Please limit response to one
(1) paragraph per faculty member.
2.
Include biographical sketches for all faculty members. They may not exceed two (2) pages for each faculty
member. Be sure to include information on experience relevant to the program. The two-page format that is
included should be used.
G. Page 11G - Budget Information
Provide all information requested.
Enter detailed budget of the fellowship stipend and stipend direct costs using the table provided. This budget
must equal at least $50,000 for General Neurosurgery, Neurocritical Care, Neurosurgical Oncology,
Cerebrovascular Neurosurgery, Endovascular Neurosurgery, Pediatric Neurosurgery, Peripheral Nerve Surgery,
Stereotactic and Functional Neurosurgery and $75,000 for Spine Surgery; all fellowship costs may be listed if
preferred. Allowable expenses are the fellow’s salary and benefits, research expenses, educational expenses
(travel and registration fees to nationally recognized meetings/courses; books), licenses, malpractice insurance,
etc.
1.
Provide justification for each budget category.
2.
Applicant may not use fellowship funds for indirect fellowship costs.
H. Page 12H and I pages - Other Requirements
1.
Provide answers to other requirements. Provide proof of qualification as a non-profit, charitable entity by
attaching a copy of the IRS Non-Profit Status Determination letter. If a for-profit entity, attach copy of
Page 7
letter of affiliated non-profit entity. Fellowship Program Director and Department Chairman - sign and date
the application.
I.
Correspondence:
Completed application and required copies/documents should be forwarded to:
Sourma Khoury
Development Coordinator
5550 Meadowbrook Drive
Rolling Meadows, IL 60008
IV.
NREF General Neurosurgery, Neurocritical Care, Neurosurgical Oncology, Cerebrovascular Neurosurgery,
Endovascular Neurosurgery, Pediatric Neurosurgery, Peripheral Nerve Surgery, Spine Surgery and Stereotactic
and Functional Neurosurgery Grant Guidelines
A.
B.
Fellowship Grant Policies 1.
NREF Fellowship Grant funding is limited to institutions that offer post-residency clinical and research
fellowships in the neurosurgical subspecialties including but not limited to*:
a. General Neurosurgery
b. Neurocritical Care
c. Neurosurgical Oncology
d. Cerebrovascular Neurosurgery
e. Endovascular Neurosurgery
f. Pediatric Neurosurgery
g. Peripheral Nerve Surgery
h. Spine Surgery
i. Stereotactic and Functional Neurosurgery
2.
Institutions may receive more than one fellowship based on the outcome of the random selection process;
however, institutions are limited to one fellowship per category per year with the exception of spine where
one adult spine fellowship application and one pediatric spine fellowship application will be accepted.
Fiscal Policies and Reports:
1.
Fellowship grant payments will be made in three (3) increments: 50% by the start of the fellowship (July
2015), 40% in January 2016, and 10% after final reports are received (see #4).
2.
A financial report is required within 45 days of the conclusion of the fellowship.
3.
A final report is required to be submitted by the Fellow describing his/her experience. This report is due
within 45 days of the conclusion of the fellowship.
4.
Ten percent (10%) of the grant funds will be withheld until the reports referenced in #2 and #3 above are
received by the NREF. Upon receipt of both reports, the remaining withheld funds will be sent to the
grantee institution. The final payment will not be sent until both reports are received by the NREF.
5.
Funding for a fellowship awarded by NREF cannot be duplicated by any other outside funding source. If
the institution receives funding from another source for a fellowship awarded by NREF, the Fellowship
Program Director must notify NREF immediately and return the fellowship funding to the NREF.
Notification must be sent to Sourma Khoury at sak@aans.org.
6.
At the conclusion of the fellowships, any unexpended balance of $100 or more must be refunded to the
Foundation within forty-five (45) days together with the report of expenditures and accompanying
documentation.
7.
All final reports must be submitted electronically to nref@aans.org or mailed to the NREF, c/o AANS,
5550 Meadowbrook Drive, Rolling Meadows, IL 60008, Attention: Sourma Khoury.
8.
Separate accounting of the fellowship grant funds should be maintained at the receiving institution. These
accounts, with appropriate and related invoices and payroll information, must be available at all times to
NREF representatives.
Page 8
9.
C.
The grantee may terminate a fellowship grant prior to the planned expiration date by notifying the NREF in
writing and stating the reasons for termination. Unexpended funds must be returned to the NREF within
sixty (60) days, together with a final report of expenditures. The NREF reserves the right to terminate
fellowship grants at any time if the grantee violates the terms and conditions of the grant.
Policy on Delinquent Financial/Research Reports
The Foundation reserves the right to deny additional fellowship grants to any institution where, after proper
notification, a fellow has not submitted his/her final reports, and/or the financial officer has not submitted the
final report of expenses, as required by NREF. Further, the NREF will not issue final payments to institutions
until both reports are received.
D.
Publication
1.
The NREF encourages publication of research findings by fellows, but requires that the NREF is cited
as a source of support on the first page of the text.
2.
When a fellow presents a paper at a professional scientific meeting concerning research findings made
during the course of an NREF funded fellowship, the NREF must be cited prior to the beginning of the
presentation.
3.
The NREF should be sent reprints of all papers and publications, including any electronic papers or
publications, resulting from work done during the course of a fellowship, even those that appear after
the fellowship has concluded.
Page 9
Institution Name_____________________________
2015-2016 Neurosurgery Fellowship Grant Application
1a. Does your institution have an accredited ACGME residency
program?
_____YES
_____NO
1b. Is your Fellowship CAST accredited?
_____ YES
_____ NO
_____ Date of CAST accreditation
If yes, please attach certificate to application.
1c. Has your institution applied for CAST accreditation?
_____ YES
_____ NO
_____ Date of application
If yes, please attach copy of application.
Neurosurgery Research and Education Foundation (NREF)
5550 Meadowbrook Drive, Rolling Meadows, IL 60008
Phone: 847.378.0500
Fax: 847.378.0600
www.nref.org
Follow Instructions Carefully
2. APPLICANT INSTITUTION INFORMATION
2a. INSTITUTION NAME
2b. FEDERAL ID #
2c. INSTITUTION MAILING ADDRESS
2d. Is the applicant institution a non profit entity?
__________YES
2e. If no, provide name of affiliated non-profit entity.
__________NO
3. FELLOWSHIP CATEGORIES
3a. Fully funded spine fellowship grants will be awarded in the amount of $75,000. Depending on available support, grants may
be awarded in lesser amounts. Institutions are limited to one (1) fellowship grant per category per year with the exception of
spine where one adult spine fellowship application and one pediatric spine fellowship application will be accepted.
Funding will be awarded to the institution. Individual fellows may not apply.
Fellowship category (check appropriate category):
_____ Adult Spine
_____ Pediatric Spine
______________________________________________________________________________________________________________
3b. Fully funded non-spine fellowships will be awarded in the amount of $50,000. Please indicate the fellowship category for
which you are applying.
Fellowship category (check appropriate category):
_____General Neurosurgery
_____ Neurocritical Care
_____ Neurosurgical Oncology
_____Pediatric Neurosurgery
_____Cerebrovascular Neurosurgery
_____Endovascular Neurosurgery
_____ Peripheral Nerve
_____Stereotactic/Functional Neurosurgery
Neurosurgery Fellowship Grant Application
1A
Institution Name_____________________________
4. FELLOW INFORMATION
4a. NAME
4b. FELLOW E-MAIL (required)
5. FELLOWSHIP PROGRAM DIRECTOR INFORMATION
5a. NAME and TITLE:
5b. E-MAIL ADDRESS (required)
5c. MAILING ADDRESS
5d. TELEPHONE (Area code, number, extension)
Phone:
6. FELLOWSHIP PROGRAM COORDINATOR INFORMATION
8a. NAME and TITLE:
8b. E-MAIL ADDRESS (required)
8d. TELEPHONE AND FAX (Area code, number, extension)
Phone:
Fax:
6. DEPARTMENT CHAIRMAN COORDINATOR INFORMATION
6a. NAME (include title)
6b. E-MAIL ADDRESS (required)
6c. MAILING ADDRESS
6d. TELEPHONE (Area code, number, extension)
Phone:
7. FINANCIAL OFFICER INFORMATION
10a. NAME and TITLE:
10b. E-MAIL ADDRESS (required)
10c. TELEPHONE (Area code, number, extension)
10e. INSITUTION IDENTIFICATION NUMBER #
8. PAYEE INFORMATION
11a. Check Payable To:
11b. MAILING ADDRESS FOR CHECK – include name of person to receive check
Neurosurgery Fellowship Grant Application
2A
Institution Name_____________________________
9. APPLICANT CERTIFICATION AND ACCEPTANCE:
I certify, on behalf of the applicant, that the statements herein are true, complete and accurate to the best of my knowledge, and accept the
obligation to comply with NREF’s terms and conditions if a fellowship grant is awarded as a result of this application. I further certify that
the applicant understands that any deliberate omission or the misrepresentation or falsification of any of the information contained in this
application or in any other communication by the applicant to NREF related to this application may void any fellowship grant awarded to
the applicant institution by NREF and may require the applicant institution to refund any such grant.
SIGNATURE OF FELLOWSHIP PROGRAM DIRECTOR NAMED IN #5:
(In ink. “Per” signature not acceptable)
Date:
SIGNATURE OF DEPARTMENT CHAIRMAN NAMED IN #6:
(In ink. “Per” signature not acceptable)
Date:
Neurosurgery Fellowship Grant Application
3A
Institution Name_____________________________
Type the name of the Institution at the top of each printed page and each continuation page.
GENERAL NEUROSURGERY, NEUROCRITICAL CARE, NEUROSURGICAL ONCOLOGY,
CEREBROVASCULAR NEUROSURGERY, ENDOVASCULAR NEUROSURGERY, PEDIATRIC
NEUROLOGIC SURGERY, PERIPHERAL NERVE, SPINE SURGERY, STEREOTACTIC AND
FUNCTIONAL NEUROSURGERY FELLOWSHIP GRANT INFORMATION
Table of Contents - Application
Institution, Fellowship Categories, Fellow Information, .............................................................................................................................1A
Fellowship Program Director, Department Chairman, Fellowship Program Coordinator, Alternate Contact ...........................................2A
Financial Officer, Payee Information ..........................................................................................................................................................2A
Applicant Certification And Acceptance………………………………………………………………………………………………......3A
Table of Contents ........................................................................................................................................................................................ 4B
Fellowship Selection Process & Completion Requirements ....................................................................................................................... 5C
Fellowship Program Overview…………………………………………………………………………………………………………….6D
Summary of Program Requirements ........................................................................................................................................................... 7E
Fellowship Program Faculty/Biographical Sketch (not to exceed two pages per faculty member) ...................................................... 8F-9G
Budget Information and Detailed Budget .................................................................................................................................................10H
Other Requirements ................................................................................................................................................................................... 11I
Continuation Page/Other/Signatures .......................................................................................................................................................... 12J
Neurosurgery Fellowship Grant Application
4B
Institution Name_____________________________
12. FELLOWSHIP SELECTION PROCESS & COMPLETION REQUIREMENTS
Please provide the following information on the fellow who has been selected and the fellow’s qualifications.
Fellow’s Name ____________________________________________ Phone___________________________________________
12a. Fellow’s qualifications (specify where medical training and residency were completed)
12b. Briefly describe the fellow selection process.
12c. Briefly describe the institutional policies that guide fellow selection.
12d. Describe the institution’s fellowship completion requirements.
12e. Is fellow considered a faculty member or instructor? If yes, does the institution bill for any services provided by the
fellow? If so, please specify the particular services that are billed. Please also provide an estimate, based on historical data
if available, of the receivables that will be collected by the institution for services provided by the fellow.
Neurosurgery Fellowship Grant Application
5C
Institution Name_____________________________
13. FELLOWSHIP PROGRAM OVERVIEW
13a. Number of fellowships per year
__________
13b. Length of the fellowship (include dates of fellowship)
__________
13c. Number of years the fellowship program has been in place
__________
13d. Number of years the fellowship program has received funding
__________
13e. Total number of fellows trained since program was established
__________
13f. What neurologic sub-specialty is the fellowship under?
13g. Is the fellowship accredited by the Society of Neurological Surgeons (CAST)
If no, has the institution applied for CAST accreditation for the fellowship?
13h. Does the institution have a neurosurgery residency program?
Neurosurgery Fellowship Grant Application
________________________________
____ YES
_____ NO
____ YES
_____ NO
_____YES
_____NO
6D
Institution Name_____________________________
14. SUMMARY OF AND COMPLIANCE WITH PROGRAM REQUIREMENTS ESTABLISHED BY THE
SOCIETY OF NEUROLOGICALSURGEONS’ COMMITTEE ON ACCREDITATION OF SUBSPECIALTY
TRAINING (CAST) FOR FELLOWSHIP EDUCATION [www.societyns.org/fellowships]
14a. Provide a concise overview of the educational program.
14b. Describe the fellowship’s clinical components.
14c. Provide a description of opportunities fellows have for research relative to the fellowship subspecialty area.
14d. Briefly describe the opportunities fellows have to participate in scholarly activity, including the education of
neurosurgery residents and medical students.
14e. List the regular dedicated teaching conferences/learning opportunities available to fellows (use continuation page if
needed).
Neurosurgery Fellowship Grant Application
7E
Institution Name_____________________________
15. FELLOWSHIP PROGRAM FACULTY
Demonstrate that the faculty is properly trained, properly accredited, and sufficient in size to provide adequate
instruction and supervision of fellows. Include information sufficient to show that the faculty members have the
necessary expertise and competence in clinical care, are in good standing and have appointments at the participating
institution.
15a. List each faculty member associated with this fellowship. Describe their qualifications and role in the
program.
Faculty Members
Comments
15b. Include a two-page Biographical Sketch for all faculty members. This may not exceed two-pages for each person.
Be sure to include experience relevant to the fellowship program. The two-page format that is included on the
following page should be used.
Neurosurgery Fellowship Grant Application
8F
Institution Name_____________________________
15c.
BIOGRAPHICAL SKETCH
Provide the following information for all faculty members listed on the faculty roster. Photocopy this page or follow this
format for each person.
NAME
POSITION/TITLE
BIRTHDATE
(optional)
LENGTH OF
TIME ON
FACULTY
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education and include postdoctoral
training.)
INSTITUTION /CITY/STATE
DEGREE(S)
YEAR(S)
FIELD(S) OF STUDY
PROFESSIONAL EXPERIENCE: Please describe your professional experience, particularly how it relates to your
involvement in the fellowship program.
Include: Academic appointments, professional activities and a selected bibliography
DO NOT EXCEED TWO PAGES, INCLUDING CONTINUATION PAGE.
Neurosurgery Fellowship Grant Application
9G
Institution Name_____________________________
16. BUDGET INFORMATION
16a. Have you applied for funding for this Fellowship from other funding sources:
_____YES
____NO
_____YES
_____NO
16b. If yes, please state source(s).
16c. If yes, have you received funding for this fellowship?
If Yes, please state $ amount _____________________
16d. DETAILED BUDGET
Personnel expenses – including salary and fringe benefits. Grant is intended to fund salary and benefits
first.
Research Expenses
Educational Expenses
Other expenses (please list)
TOTAL FELLOWSHIP BUDGET
(Must equal at least $75,000 for spine applications, $50,000 for General Neurosurgery, Neurocritical Care,
Neurosurgical Oncology, Cerebrovascular Neurosurgery, Endovascular Neurosurgery, Pediatric
Neurosurgery, Peripheral Nerve Surgery, Stereotactic and Functional Neurosurgery
$
Total actual cost of training this fellow if not included above
$
Neurosurgery Fellowship Grant Application
10H
Institution Name_____________________________
16e. BUDGET JUSTIFICATION - Please provide justification for each budget category. Use continuation pages as needed.
Fellowship funds may not be used for indirect fellowship costs.
Neurosurgery Fellowship Grant Application
10H
Institution Name_____________________________
17 OTHER REQUIREMENTS
17a. Does the fellowship program director maintain accurate case logs of the neurosurgery case material operated within
the institution and the subspecialty experience of the residents as well as the fellow?
17b. Is the fellow expected to maintain an accurate prospective case log of his/her operative cases throughout the fellowship
period? Please describe how this information is documented.
17c. Briefly describe the fellow evaluation process and the process the fellows use to evaluate the faculty and fellowship
program. How often do these occur?
17d. Does the program ensure that duty hours and work conditions for fellows is consistent with ACGME institutional and
program requirements for residency training in neurological surgery? Please describe.
Neurosurgery Fellowship Grant Application
11I
Institution Name_____________________________
18. OTHER REQUIREMENTS
18a. Please provide proof of qualification as a non-profit, charitable entity. Attach a copy of IRS Determination letter
which should include the institution’s status, including the federal ID number.
CONTINUATION PAGE
CHICAGO/#2333636.2
Neurosurgery Fellowship Grant Application
12J
Institution Name_____________________________
Signature of Fellowship Program Director:
Signature ______________________________________________ Date __________________________
Signature of Department Chairman:
Signature _______________________________________________Date___________________________
Neurosurgery Fellowship Grant Application
12J