Request Change in Program Complement Date* MM slash DD slash YYYY Program Name*Program Director* First Last PD Phone*PD Email* Department Chair* First Last Core Program Director (if applicable) First Last Current Approved Resident/Fellow Complement*Please enter a number greater than or equal to 0.Requested Approved Resident/Fellow Complement*Please enter a number greater than or equal to 0.Requested Effective Date* MM slash DD slash YYYY Rationale, Impact and Financing for Requested Complement IncreaseProvide a brief description of the educational reasons for the fellow complement change. This may include the exposure of fellows to new technology and the development of rotations that amplify or expand educational experiences. The narrative should justify the request in terms of institutional support, funding, emerging technology, clinical experiences, faculty support, and other institutional facilities that are available. Include the proposed implementation plan. The rationale must be exclusively educational and not based on specialty demands.*How will additional positions be financed?*Please attach a letter of support from your department administrator signed by your Department Chair*Max. file size: 15 MB. This field is hidden when viewing the formWhat will be the impact of the change on the educational program?*Please include both the positive and negative effects on the educational program in comparison to the current program size.What are the anticipated effects of your proposed program changes on other training programs at UAMS?* (i.e. Availability of patients, resources) Will this create competition for patients or faculty supervision?How will the change affect the number of cases seen by the trainees?*If your RRC or American Board have requirements for a certain number of rotations, clinical experience, number of producers, cases, etc., will there be adequate experiences to meet RRC and Board requirements?*Assuming approval, will the curriculum be modified for any year(s) of training?* Yes No What will be added, deleted or moved?*Include a Block diagram by PGY year, for a model resident / fellow Drop files here or Select files Max. file size: 15 MB. How will this change affect the balance of Service vs. Education?*How will this affect Work Hours for each program year?*Will there be additional or new training sites needed to accommodate the change in trainee complement?* Yes No Please list the additional sites that will be utilized.You will be required to provide an PLA and/or affiliation agreement before the start of the training (at the point of RRC Submission).Is there adequate space and resources (offices, desks, computers, labs, etc) to accommodate the change?*Please provide a summary of necessary resources.Program-Specific FTE RequirementsAcknowledgement*Program has reviewed their program-specific FTE requirements and have answered the following questions to the best of their knowledge. I have reviewed my program-specific FTE requirements.This requested change to ACGME-approved positions will require a change in FTE for the Program Director* Yes No This requested change to ACGME-approved positions will require a change in FTE for theAssociate Program Director* Yes No This requested change to ACGME-approved positions will require a change in FTE for theCore Faculty* Yes No This requested change to ACGME-approved positions will require a change in FTE for theProgram Coordinator* Yes No Program has received approval to implement any needed FTE changes from department leadership.* Yes No
