Request Change in Program Complement Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Program Name * Required Program Director * Required First Last PD Phone * RequiredPD Email * Required Department Chair * Required First Last Core Program Director (if applicable) First Last Current Approved Resident/Fellow Complement * RequiredPlease enter a number greater than or equal to 0.Requested Approved Resident/Fellow Complement * RequiredPlease enter a number greater than or equal to 0.Requested Effective Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Rationale, Impact and Financing for Requested Complement IncreaseReason(s) for request to change the number of trainees in program: * RequiredHow will additional positions be financed? * RequiredPlease attach a letter of support from your department administrator signed by your Department Chair * RequiredMax. file size: 15 MB.What will be the impact of the change on the educational program? * RequiredPlease 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? * Required (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? * RequiredIf 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? * RequiredAssuming approval, will the curriculum be modified for any year(s) of training? * Required Yes No What will be added, deleted or moved? * RequiredInclude 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? * RequiredHow will this affect Work Hours for each program year? * RequiredWill there be additional or new training sites needed to accommodate the change in trainee complement? * Required 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? * RequiredPlease provide a summary of necessary resources.
