New Program Form New Program Form Step 1 of 6 – Program Information 16% Program Name:*Program Director candidate:*Associate/Assistant Program Director candidate:(if applicable)Program Coordinator candidate:*How will having this program serve the patients within the UAMS system?*How will having this program serve the patients of Arkansas*Describe the protected time needed for educational and administrative responsibilities of the program for the program director (must meet the ACGME minimum requirements):* Does the PD candidate meet the following qualifications outlined by the ACGME:Requisite specialty expertise* Yes No Please explain:Documented educational experience* Yes No Please explain:Documented administrative experience* Yes No Please explain:Current certification in the specialty* Yes No List name and date of certificationsCertification NameDate of Certification Current medical licensure and appropriate medical staff appointment* Yes No Please explain:Meets specialty specific requirements for number of years as a faculty member in an ACGME-accredited program*(if applicable) Yes No Please explain:Meets specialty specific requirements for expected time for PD*(if applicable) Yes No Please explain: What is the PD candidates proposed term of appointment as PD?* <6 months Interim: >= 6 months and <2 years >2 years and <6 years Indefinite >6 years List all participating institutions of clinical sites to which the residents/fellows will rotate:*NameLocation At each participating site, are there sufficient number of faculty members with documented qualifications to instruct and supervise all residents at that location per ACGME requirements?* Core FacultyCore faculty is defined as physicians who devote at least 15 hours per week to resident education and administration. See specific program requirements for other qualifications of core faculty. PDs will not be designated as core faculty. List your core faculty* Given the identified core faculty, have you considered if they have enough scholarly activity to meet the requirements of your program.* Yes No How many of your core faculty have two or more articles published with PubMed IDs?* Number of articles published with PubMed IDs.*Number of abstracts, posters, and presentations given at international, national, or regional meetings.*Number of other presentations given (grand rounds, invited professorships), materials developed (such as computer-based modules), or work presented in non-peer review publications. Articles without PMIDs should be counted in this section. This will include publication which are peer reviewed but not recognized by the National Library of Medicine.*Number of chapters or textbooks published.*Number of grants for which faculty member had a leadership role (PI, Co-PI, or site director).*Number of active leadership roles (such as serving on committees or governing boards) in national medical organizations or served as reviewer or editorial board member for a peer-reviewed journal.*Number of faculty that held responsibility for seminars, conference series, or course coordination (such as arrangement of presentations and speakers, organization of materials, assessment of participants' performance) for any didactic training within the sponsoring institution or program. This includes training modules for medical students, residents, fellows and other health professionals. This does not include single presentations such as individual lectures or conferences.* Describe the full costs of the program.*Please attach a proposed budget for 3 years of the program, including initial cost of starting a new program set by the ACGME ($6,800), cost of resident/fellow stipends (include 26% of stipend for benefits and liability insurance), faculty salary, outside speakers, research costs, recruitment costs, etc. Max. file size: 15 MB.Describe the source of resident/fellow stipends and benefits (UAMS, ACH, VA, other rotation sites). What hospital representative has agreed to this funding?*
