Autonomic Disorders
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: December 2013
©2013
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]
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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.’
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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
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February
March
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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.
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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
Amount of time in months (e.g., 40 half days=1 month)
Year 2
Not applicable
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
Amount of time in months (e.g., 40 half days=1 month)
Year 3
Not applicable
1
BLOCK ROTATIONS
2
3
4
5
6
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7
8
9
10
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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.
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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:
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ACGME
Competency
Objective
Type(s)
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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
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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
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YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
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Appendix G: Duty Hours Compliance
Please submit a copy of the policy on duty hours and a call schedule to complete Appendix G.
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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
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June 30,
June 30,
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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.
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Appendix J: Autonomic Disorders Specific
Please respond to the following:
1. Please indicate if the program has at least one clinical autonomic testing laboratory with adequate
equipment, laboratory space, and office facilities to provide full-spectrum testing of the autonomic nervous
system.
Yes
No
2. Please indicate if the program has the resources for fellows to complete:
1. at least two tests of cardiovascular sympathetic function
2. at least two tests of parasympathetic testing
3. at least one type of sudomotor autonomic testing
Yes
Yes
Yes
No
No
No
3. Do fellows in this program assume a supervised clinical management role for at least 100 new patients with
complaints related to the autonomic nervous system?
Yes
No
4. Describe how fellows will participate in performing and interpreting clinical autonomic laboratory testing
and estimate the number of patients per year, ensuring that the number is at least 100 patients.
5. Please attest that the didactic components listed below are included in the program and documented in
Appendix E: Formal Didactics*:
a. Anatomical organization of the central autonomic control centers, the parasympathetic, sympathetic
and enteric nervous systems, and visceral afferents,
Yes
No
b. Basics of cardiovascular, respiratory, gastrointestinal, pupillary, sudomotor, and other autonomic
reflexes,
Yes
No
c. Basis of autonomic neurotransmission, including neurotransmitter synthesis, distribution, and release
mechanisms, receptor subtypes, effects on their target organs,
Yes
No
d. Anatomic pharmacology, including pharmacokinetics and pharmacodynamics of drugs affecting the
ANS,
Yes
No
e. Clinical and laboratory diagnosis of central and peripheral disorders of autonomic function, including
neurodegenerative disorders associated with generalized anatomic failure, peripheral autonomic
neuropathies, focal or target-specific autonomic syndromes, and effects of drugs,
Yes
No
f. Indications, techniques, and limitations of noninvasive recordings of arterial pressure, heart rate and
sudomotor output, including theoretical and practical knowledge of the equipment used to obtain
those recordings,
Yes
No
g. Performance, supervision, and interpretation of tests of: orthostatic tolerance (heart rate and blood
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pressure responses to standing or passive head-up tilt); cardiovagal function (including heart rate
response to deep breathing); Valsalva maneuver; and sudomotor function,
Yes
No
h. Interpretation of the results of the humoral, microneurography, and power spectral analysis
evaluation of autonomic function,
Yes
No
i. Interpretation of tests of pupillary function, gastrointestinal motility, urodynamics, penile erection,
and thermography,
Yes
No
j. Expertise in nonpharmacological and pharmacological management of orthostatic intolerance
syndromes (including orthostatic hypotension, syncope, and postural tachycardia), gastrointestinal
dysmotility, neurogenic bladder, and sudomotor disorders, and
Yes
No
k. Knowledge of the complex pathophysiological mechanisms involved in neuropathic pain syndromes
(including complex regional pain syndromes), and application and limitations of autonomic testing to
help determine the contribution of sympathetic outflow to pain and to vasomotor and sudomotor
components of the syndrome.
Yes
No
* Please note: failure to clearly list all required components in Appendix E will require submission of additional
information.
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