Request for Non-ACGME Accredited Training Program Program InformationProgram Name:(Required) Most Closely Related ACGME Specialty Program:(Required) Is there an ACGME Accredited Pathway for this Program?(Required) Yes No Please Describe Why You Would Not Be Applying Through The ACGME.(Required)Please List the Accrediting Body for This Program:(Required) Length of Program in Months:(Required)Provide the Rationale for the Length of Program if Longer Than One Year:(Required)Number of Trainees Per Year:(Required)Prerequisite Education/Training for Entry Into the Program:(Required)Would This Program Ever Offer a Position to a Candidate that Holds a J-1 Visa?(Required) Yes No Please Review ACGME Non-Standard Training Recognition Program Requirements.(Required) I have read and acknowledge these requirements.https://www.acgme.org/programs-and-institutions/institutions/non-standard-training-nst-recognition/ Program Leadership InformationProposed Program Director Name:(Required) First Last Proposed Program Director Email:(Required) Is Proposed Program Director Candidate a Faculty Member of the Most Closely-Related ACGME Accredited Program(Required) Yes No Please Provide the Following Information for the Proposed Program Director Candidate:(Required)Board Certification that Meets Program RequirementsCurrent Faculty AppointmentExpertise in Proposed Training ProgramAttach Proposed Program Director's CV:(Required) Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 15 MB. Program Coordinator Name:(Required) First Last Program Coordinator Email:(Required) List All Faculty Members Who Have Responsibility for Education or Supervision of the Program:(Required) Add RemoveProgram Rotation InformationParticipating Sites for Rotations (UAMS, ACH, VA, etc.):(Required) Attach Proposed Block Schedule with Participating Site Information.(Required) Drop files here or Select files Max. file size: 15 MB. Program Education InformationDefine the Educational Goals of the Program:(Required)Describe the Required Educational Experiences and Didactic Sessions in the Program:(Required)Is This Primarily a Research Program?(Required) Yes No Does the Program Have Procedural Experience Requirements?(Required) Yes No Program Supervision and EvaluationDescribe the Supervision of Trainees in the Program:(Required)Describe the Methods of Assessment of Trainees in the Program:(Required)Impact of Program on Existing ACGME Accredited ProgramsDescribe the Impact of this Program on the Education of Residents/Fellows in Existing UAMS ACGME Accredited Programs.(Required)Please Identify the Number of Residents/Fellows from Existing Programs that will Interact with the Program's Trainee (s):ACGME Approved TraineesPGY-1(Required) PGY-2(Required) PGY-3(Required) PGY-4(Required) PGY-5(Required) PGY-6(Required) PGY-7(Required) PGY-8(Required) Any Other TraineesPGY-1(Required) PGY-2(Required) PGY-3(Required) PGY-4(Required) PGY-5(Required) PGY-6(Required) PGY-7(Required) PGY-8(Required) Please Specify Other Trainees:(Required) Total Current TraineesPGY-1(Required) PGY-2(Required) PGY-3(Required) PGY-4(Required) PGY-5(Required) PGY-6(Required) PGY-7(Required) PGY-8(Required) Outline How the Program is Funded:(Required) Drop files here or Select files Max. file size: 15 MB.
