THE RESIDENCY REVIEW COMMITTEE FOR EMERGENCY MEDICINE

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					                   RESIDENCY REVIEW COMMITTEE FOR EMERGENCY MEDICINE
                         515 N State, Ste 2000, Chicago, IL 60610  (312) 755-5028  www.acgme.org

                                           PROGRAM INFORMATION FORM

                                           FOR NEW APPLICATIONS ONLY

GENERAL INSTRUCTIONS
APPLICATION FOR A NEW PROGRAM: This form is for use by programs making Initial Application Only. All sections of the
form applicable to the program must be completed in order to be accepted for review. The information provided should
describe the proposed program. For items that do not apply indicate N/A in the space provided. Where patient numbers are
requested, estimate what you expect will occur. If any requested information is not available, an explanation should be given
and it should be so indicated in the appropriate place on the form.

Note that the process takes approximately one year from the time the application is received until it is evaluated by the
Residency Review Committee. A site visit will be scheduled during that year.

The Institutional Requirements, the Program Requirements, and the PIF may be downloaded from the ACGME Website
(www.acgme.org) and should be reviewed carefully.

Once the forms are complete, number the pages sequentially in the upper right hand corner, starting with Part 1, Section 1.
Send four complete copies to the Executive Director of the RRC for Emergency Medicine at the given address above. Supply
information that will indicate when you expect the program to be activated. The data and description given must be realistic
and evidence should be included that your expectations are reasonable.

The Program Director is personally responsible for the content of the completed forms. All sections of the form must be
completed for the program information forms to be accepted for review. If any requested information is not applicable or not
available, an explanation should be given and it should be so indicated in the appropriate place on the forms. The forms will
not be considered complete without the appropriate signatures on the first page. The recommendation of the Residency
Review Committee will be based to a large extent upon the information submitted here. By signing, the Program Director
attests to the accuracy of the information submitted. It must also be signed by the Department Chair/Chief of Service and the
Designated Institutional Official of the sponsoring institution.

REVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the program information form is
being completed for a currently accredited program, this is not the correct form: use the Continued Accreditation PIF in
conjunction with the Web Accreditation Data System (Web ADS). Follow the provided instructions to create the correct PIF. Go
to the Web Accreditation Data System (Web ADS) found on the ACGME home page (www.acgme.org), using your previously
assigned username and password, update your program and resident data, retrieve Part 1 of the PIF under the Site Visit
Information section, complete the shaded items (as appropriate), print all sections of Part 1 of the PIF and sign the form. If
you find items displayed incorrectly change your data using ADS update sections; in some instances you may need to contact
your DIO for the entry of updated information. Next proceed to the section under the RRC for Emergency Medicine to retrieve
Part 2 of the PIF for continued accreditation in either Word or WordPerfect. Complete Part 2 of the PIF using your preferred
word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pages consecutively on the
upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents (found with the Part 2 instructions).
Ten working days prior to the visit send one copy of the entire packet to the site visitor identified in your letter. After the visit
send 3 copies to the Executive Director, Residency Review Committee for Emergency Medicine, 515 North State Street,
Chicago, IL 60610.

PROGRAM REQUIREMENTS: Carefully read the current Program Requirements for Residency Education in Emergency
Medicine and the Institutional Requirements before completing these forms. You are being asked to provide information based
on these requirements.

QUESTIONS: If you have questions concerning the completion of these program information forms, contact the Accreditation
Administrator at (312) 755-5028 or the Executive Director at (312) 755-7464.

GENERAL INFORMATION: Instructions have been provided at the beginning of each section of the PIF. Please read them
carefully before providing information. Note that only these forms are to be used for supplying information and only requested
information is to be attached. If you elect to reproduce these forms on a word processing system, the resulting product must
be identical to these forms. The information being submitted should be as concise as possible. Do not attach any unnecessary
materials such as curriculum vitae, reprints, brochures, annual reports, minutes of meetings, etc. The RRC will not review
unsolicited preprinted materials.



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The forms are designed so that all information regarding intramural or multi-institution programs can be included on one set of
forms. A complete set is to be sent to each participating institution so it can provide its own statistics. The same reporting
period must be used by all participating institutions. Information is to be collected by the Program Director for consolidation
and transfer to a single set of forms. The Program Director is responsible for overseeing the accurate compilation of requested
data for all participating institutions. When the Program Director provides the forms to participating institutions, he/she should
designate each institution as Institution # 2, 3, or 4, etc. For "MONTHS RESIDENT IS ON CLINICAL ROTATION," give the
total number of full-time equivalent months that each emergency medicine resident spends in that institution in each year of
training. For "LOCAL TRAINING DIRECTOR," list the person who supervises resident training in emergency medicine at that
institution. Also note that "PY1" refers to the first year of the emergency medicine training regardless of how many post
graduate years the resident had before entering the emergency medicine residency.

The Program Information Forms (PIFs) are structured to conform to the order of the Program Requirements. The forms must
be legibly typed. Hand-written submissions will not be accepted.

AFFILIATION AGREEMENT(S): If the program information forms comprise an initial application for accreditation of a program,
copies of current, signed affiliation agreements with each participating institution where clinical training takes place must
accompany the forms (Attachment P.R. II.B). If the program has an affiliation with a medical school, a copy of the affiliation
agreement must be inserted (Attachment P.R. II.A). For the review of an existing program, current, signed affiliation
agreements must be available for inspection by the site visitor. If the program is seeking approval to add a participating
institution, a current, signed affiliation agreement must accompany these forms. All affiliation agreements must conform to the
Institutional Requirements.

STATISTICAL INFORMATION: Statistics are to be provided for the most recent full year (preferably an academic year of July
1st to June 30th) for which this information is available. The same reporting period must be used by all of the participating
institutions. Forms must be typed. All copies must be legible. Computer print-outs or any other method employed in reporting
INSTITUTIONAL statistics to the Residency Review Committee will not be accepted. Only the document provided is to be
used.

SIGNATURES: The Program Director is personally responsible for the content of the completed program information forms. All
sections must be completed for the forms to be accepted for review. Forms will not be considered complete without the
appropriate signatures. By signing, the Program Director attests to the accuracy of the information being submitted. The
Designated Institutional Official is also required to sign the PIF prior to submission.

EXAMPLES: For some sections of the program information forms, an example page has been provided as guidance for
completing the form. The example is not intended to indicate the right way to do any particular program component but merely
to provide a sample of a correctly completed form. Do not insert your program information on the example pages and do not
submit the example pages with your final copies of the forms.

ATTACHMENTS: In some sections of the Program Information Forms, an Attachment or Addendum is requested. In these
circumstances, please insert the Attachment directly following the applicable section of the PIF. Do NOT collect all the
Addenda at the end of the PIF.




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GLOSSARY OF TERMS
I.R.: Abbreviation for Institutional Requirements.

P.R.: Abbreviation for Program Requirements.

Applicants: Persons invited to come for an interview for a GME program.

Categorical Positions (see also "Graduate Year 1" and "Preliminary Positions"): Positions for residents who begin and
remain in a given program or specialty until completion of the year(s) required for admission to specialty board examination.

Consortium: Two or more organizations or institutions that have come together to pursue common objectives (e.g., GME). A
consortium may serve as a "sponsoring institution" for GME programs if it is formally established as an ongoing institutional
entity with a documented commitment to GME.

Designated Institutional Official (DIO): The person in a sponsoring institution of GME who assumes the authority and
responsibility for the GME programs and oversees the implementation of the Institutional Requirements. The DIO is
responsible for completing the Annual Update for the Web Accreditation Data System and seeing that all sponsored programs
complete their updates on schedule.

Desirable: A term, along with its companion "highly desirable”, used to designate aspects of an educational program that are
not mandatory but are considered to be very important. A program may be cited for failing to do something that is desirable or
highly desirable.

Essential: (See “Must”)

Fellow: A term used by some sponsoring institutions and in some specialties to designate participants in subspecialty GME
programs. Such physicians may also be termed "resident" as well. Other uses of the term "fellow" require modifiers for
precision and clarity, e.g. "research fellow."

Institution:    An organization having the primary purpose of providing educational and/or health care services (e.g., a
university, a medical school, a hospital, a school of public health, a health department, a public health agency, an organized
health care delivery system, a medical examiners office, a consortium, an educational foundation).

     Major Participating Institution: An institution to which residents rotate for a required experience and/or those that require
     explicit approval by the appropriate RRC prior to utilization. Major participating institutions are listed as part of an
     accredited program in the Graduate Medical Education Directory.

     Other Participating Institution: An institution that provides specific learning experiences within a multi-institutional
     program of GME. Subsections of institutions, such as a department, clinic, or unit of a hospital, do not qualify as
     participating institutions.

     Sponsoring Institution: The institution that assumes the ultimate (financial and academic) responsibility for a program of
     GME.

Institutional Review: The process undertaken by the ACGME to judge whether a sponsoring institution offering GME
programs is in substantial compliance with the Institutional Requirements.

Integrated Institution: Applicable for programs where the RRC monitors this type of designation. See program requirements
for specialty specific details.

Intern:    Historically, "intern" was used to designate individuals in the first year of GME; less commonly it designated
individuals in the first year of any residency program. Since 1975 the Graduate Medical Education Directory and the ACGME
have not used the term, instead referring to individuals in their first year of GME as residents.

Internal Review: The formal process undertaken by a sponsoring institution of its individual ACGME-accredited programs in
conformity with Section I.B.3.c. of the Institutional Requirements to evaluate the sponsored programs.

International Medical Graduate (IMG): A graduate from a medical school outside the United States and Canada (and not
accredited by the Liaison Committee on Medical Education (LCME)). IMGs may be citizens of the United States or Canada
who chose to be educated elsewhere or non-citizens who were admitted to the United States by US immigration authorities. All
IMGs should undertake residency training in the United States before they can obtain a license to practice medicine in the
United States even if they were fully trained, licensed, and practicing in another country.




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Intramural Program:         A program conducted within a single institution. The assignment of residents is limited to that
institution.

Medical School Affiliation: Institutions that sponsor an accredited program may have a formal relationship with a medical
school. Indicate that a medical school affiliation exists for an institution (or program) if the institution (or program) is an
important part of the teaching program for the medical school. Do not include only brief, occasional, and/or unique rotations of
students or residents.

Months of Rotation: Refers to the total number of months a typical resident spends at an institution. If the total number of
months that each resident spends at a location is different for different residents, use the average (a decimal number may be
reported).

Must (Shall, Essential): Terms used to indicate that something is required, mandatory, or done without fail. These terms
indicate absolute requirements.

Ownership Type of Institution: Refers to the governance, control or type of ownership of the institution.

Program: The unit of specialty education, comprising a series of graduated learning experiences in GME, designed to
conform to the program requirements of a particular specialty.

Preliminary Positions (see also "Graduate Year 1"): Positions for residents who are obtaining training required to enter
another program or specialty. Some residents in preliminary positions may move into permanent positions in the second year.
Preliminary positions are usually 1 year in length and usually offered for Graduate Year 1. Internal medicine, surgery, and
transitional year programs commonly offer preliminary positions.

Preliminary Designated Positions: Residents matched by/for other specialties. The resident is designated as having a
permanent position after completing the preliminary year(s). Specialties that do not designate preliminary positions will use this
option to indicate preliminary positions.

Preliminary Non-Designated: Residents accepted into the program for 1 or 2 years of training; these residents do not have
designated permanent positions in the current program or another program at time of acceptance.

Principal Teaching Hospital: If the sponsoring institution is a hospital, it is by definition the principal teaching hospital for the
residency program. If the sponsoring institution is a medical school, university or consortium of hospitals, the hospital that is
used most heavily in the residency program is the principal teaching hospital. If two or more hospitals are used equally, each
can be considered the principal teaching hospital. This is the institution where most of the training takes place.

Program Director:       The official responsible for maintaining the quality of a GME program so that it meets ACGME
accreditation standards. Other duties of the Program Director include preparing a written statement outlining the program's
educational goals; providing an accurate statistical and narrative description of the program as requested by the Residency
Review Committee (RRC); and providing for the selection, supervision, and evaluation of residents for appointment to and
completion of the program.

Program Merge/Split/Absorption: In a merge, two programs combine to create one new program; the new program
becomes the accredited unit and accreditation is voluntarily withdrawn from both former programs. In a split, one program
divides into two separate programs and each program receives accreditation. In absorption, one program takes over the other
program; the absorbed program is granted voluntary withdrawal status, while the other program remains accredited.

Program Letters of Agreement: The sponsoring institution must ensure that for each accredited program appropriate letters
of agreement exist between the sponsoring institution and the participating institutions used by a program that provides
specific learning experiences.

Program Year (see also "Graduate Year"): Refers to the current year of training within a specific program; this may or may
not correspond to the graduate year. For example, a resident in pediatric cardiology could be in the first program year of the
pediatric cardiology program but in his/her fourth graduate year of GME (including 3 prior years of pediatrics). The Web
accreditation data systems track residents according to his/her current year in the program, regardless of prior training.

Resident: A physician at any level of GME in a program accredited by the ACGME. Participants in accredited subspecialty
programs are included. Other uses of the term "resident" require modifiers.

Scholarly Activity: Educational experiences that include active participation of the teaching staff in clinical discussions,
rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship; active participation in journal clubs,
research conferences, regional or national professional and scientific societies, particularly through presentations at the
organizations’ meetings and publications in their journals; participation in research, particularly in projects that are funded
following peer review and/or result in publications or presentations at regional and national scientific meetings; offering of
guidance and technical support, e.g., research design, statistical analysis, for residents involved in research; and provision of

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support for resident participation as appropriate in scholarly activities. May be defined in more detail in specific Program
Requirements.

Should: A term used to designate requirements that are so important that their absence must be justified. The accreditation
status of a program or institution is at risk if it is not in compliance with a "should”.

Sponsoring Institution (See also "Institution"):     The institution that assumes the ultimate responsibility for a program of
GME.

Substantial Compliance: The determination of substantial compliance results from a judgment based on all available
information as to the degree that the entity being evaluated meets accreditation standards.

Suggested: A term, along with its companion “strongly suggested”, used to indicate that something is distinctly urged rather
than required. An institution or a program will not be cited for failing to do something that is suggested or strongly suggested.

Teaching Staff: Any individual who has received a formal assignment to teach resident physicians. In some institutions
appointment to the medical staff of the hospital constitutes appointment to the teaching staff.




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                   RESIDENCY REVIEW COMMITTEE FOR EMERGENCY MEDICINE
                         515 N State, Ste 2000, Chicago, IL 60610  (312) 755-5028  www.acgme.org

                                           PROGRAM INFORMATION FORM

TABLE OF CONTENTS
When you have completed the forms, number each page sequentially in the upper right hand corner. Start on Part 1,
Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page with the completed PIF.

                                              Part 1                                            Section      Page(s)
General Program Information                                                                          1
     Accreditation Information                                                                       1.A
     Program Director Information                                                                    1.B
Participating Institutions                                                                           2
Resident Complement                                                                                  3
    Number of Positions                                                                              3.A
    Duty Hours                                                                                       3.B


                                              Part 2                                            Section      Page(s)
Background Information                                                                               4
    Program Format                                                                                   4.A
    Format Support                                                                                   4.B
    Goals of Education                                                                               4.C
Institutions                                                                                         5
    Letters of Support                                                                               5.A
    Affiliation Agreements                                                                           5.B
    Participating Institutions                                                                       5.C
    Facilities and Resources                                                                         5.D
Teaching Staff/Personnel                                                                             6
    Head of Emergency Medicine                                                                       6.A
    Program Director                                                                                 6.B
    Teaching Staff                                                                                   6.C
    Other Attending Staff                                                                            6.D
    Core Faculty Development                                                                         6.E
    Support Personnel                                                                                6.F
Patient Population                                                                                   7
    Patient Population Statistics                                                                    7.A
    Supervision                                                                                      7.B
    Progressive Responsibility                                                                       7.C
    Presence of Other Residencies and Other Educational Resources                                    7.D
    Fellowships                                                                                      7.E
    Resident Duty Hours                                                                              7.F
Block Categorical Emergency Medicine Rotation                                                        8
Conferences                                                                                          9
Curriculum - Goals and Objectives                                                                    10
    Procedures                                                                                   10.A


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                                           Part 2   Section   Page(s)
    Patient Follow-Up                                10.B
    Emergency Department Training                    10.C
    Supervision - Educational Experience             10.D
    Pre-Hospital Care                                10.E
    Major Resuscitation                              10.G
    General Competencies                             10.H
    Resident Research Experience                     10.I
    Research Education                               10.J
    Pediatric Emergency Medicine                     10.K
Evaluation                                            11
    Evaluation of Residents                          11.A
    Evaluation of Faculty                            11.B
    Evaluation of Program                            11.C
    Due Process                                      11.D

(FOR OFFICE USE ONLY)
10 Digit ACGME Program I.D. #:
Program Name:




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                    RESIDENCY REVIEW COMMITTEE FOR EMERGENCY MEDICINE
                         515 N State, Ste 2000, Chicago, IL 60610  (312) 755-5028  www.acgme.org

                                     PROGRAM INFORMATION FORM (Part 1)

                                             FOR NEW APPLICATIONS ONLY


SECTION 1. GENERAL PROGRAM INFORMATION
A.   Accreditation Information

Date:
Title of Program:

B.   Program Director Information

Name:
Title:
Address:
City, State, Zip code:
Telephone:                                 FAX:                            Email:
Date First Appointed:
Term of PD Appointment:
Primary Specialty Board Certification:                                 Most Recent Date:
Secondary Specialty Board Certification:                               Most Recent Date:
Number of years spent teaching in GME in this specialty:
Will the Program Director spend at least 50%
of his/her clinical time at the primary teaching ( ) YES     ( ) NO
institution?
Number of hours per week Director Spends in:
Clinical Supervision:                  Administration:             Research:          Didactics/Teaching:
Is Program Director also Department Chair?        ( ) YES   ( ) NO
If No, Chair Name:
The signatures of the director of the program, the chief of the department and the designated institutional official
attest to the completeness and accuracy of the information provided on these forms.
Signature of Program Director (and date):
Signature of Chief/Department Chair if different from Program Director (and date):

Signature of Designated Institutional Official (DIO) (and date):




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SECTION 2. PARTICIPATING INSTITUTIONS

SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.)
Name of Sponsor:
City, State, Zip code:
Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Name of Designated Institutional Official:
Name of Chief Executive Officer:
Does SPONSOR have an affiliation with a medical school (could be the sponsoring
                                                                                      ( ) YES               ( ) NO
institution)?
If yes, name the medical school below and have an affiliation agreement that describes the effect of these arrangements on
this program available.
Name of Medical School #1
Name of Medical School #2


PRIMARY INSTITUTION (Institution #1)
Name:
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )

Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)         Year 1:                 Year 2:      Year 3:             Year 4:
CEO/Director/President’s Name:
JCAHO Approved?
( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:



PARTICIPATING INSTITUTION (Institution #2)
                                                                                                 Select one (if applicable)
Name:                                                                                               INTEGRATED ( )
                                                                                                     AFFILIATED ( )
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )




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Does this institution also sponsor its own program in this specialty?
Does it participate in any other ACGME accredited programs in this specialty?
Distance between 2 & 1:                       Miles:                         Minutes:
Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)                            Year 1:              Year 2:   Year 3:   Year 4:
CEO/Director/President’s Name:
JCAHO Approved?
( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:




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PARTICIPATING INSTITUTION (Institution #3)
                                                                                                            Select one (if applicable)
Name:                                                                                                          INTEGRATED ( )
                                                                                                                AFFILIATED ( )
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )


Does this institution also sponsor its own program in this specialty?
Does it participate in any other ACGME accredited programs in this specialty?
Distance between 3 & 1:                       Miles:                         Minutes:
Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)                            Year 1:              Year 2:   Year 3:           Year 4:
CEO/Director/President’s Name:
JCAHO Approved?
( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:


PARTICIPATING INSTITUTION (Institution #4)
                                                                                                            Select one (if applicable)
Name:                                                                                                          INTEGRATED ( )
                                                                                                                AFFILIATED ( )
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )


Does this institution also sponsor its own program in this specialty?
Does it participate in any other ACGME accredited programs in this specialty?
Distance between 4 & 1:                       Miles:                         Minutes:
Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)                            Year 1:              Year 2:   Year 3:           Year 4:
CEO/Director/President’s Name:
JCAHO Approved?


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( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:


PARTICIPATING INSTITUTION (Institution #5)
                                                                                                            Select one (if applicable)
Name:                                                                                                          INTEGRATED ( )
                                                                                                                AFFILIATED ( )
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )


Does this institution also sponsor its own program in this specialty?
Does it participate in any other ACGME accredited programs in this specialty?
Distance between 5 & 1:                       Miles:                         Minutes:
Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)                            Year 1:              Year 2:   Year 3:           Year 4:
CEO/Director/President’s Name:
JCAHO Approved?
( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:




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PARTICIPATING INSTITUTION (Institution #6)
                                                                                                            Select one (if applicable)
Name:                                                                                                          INTEGRATED ( )
                                                                                                                AFFILIATED ( )
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )


Does this institution also sponsor its own program in this specialty?
Does it participate in any other ACGME accredited programs in this specialty?
Distance between 6 & 1:                       Miles:                         Minutes:
Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)                            Year 1:              Year 2:   Year 3:           Year 4:
CEO/Director/President’s Name:
JCAHO Approved?
( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:


PARTICIPATING INSTITUTION (Institution #7)
                                                                                                            Select one (if applicable)
Name:                                                                                                          INTEGRATED ( )
                                                                                                                AFFILIATED ( )
Address:
City, State, Zip Code:
Type of Relationship with Program:
Sponsor ( )
Major ( )
Clinical ( )
Other ( )


Does this institution also sponsor its own program in this specialty?
Does it participate in any other ACGME accredited programs in this specialty?
Distance between 7 & 1:                       Miles:                         Minutes:
Type of Rotation
Elective ( )
Required ( )
Both ( )
(select one)


Length of Resident Rotation (in months)                            Year 1:              Year 2:   Year 3:           Year 4:
CEO/Director/President’s Name:
JCAHO Approved?


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( ) ( )
YE NO
S
( ) NA


Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School)
Brief Educational Rationale:




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SECTION 3. RESIDENTS
A.   Number of Positions

                                                     Year 1                       Year 2                       Year 3                      Year 4
                Positions                                                                                                                                          Total
                                           NDP      P      C      CB    NDP      P      C      CB    NDP      P      C     CB     NDP     P      C      CB
Number (range) of Positions Requested

Type of Positions

NDP       Preliminary Non–Designated       Residents accepted into the program for 1 or 2 years of training; these residents do not have designated permanent positions in
                                           the current program or another program at time of acceptance.

P         Preliminary Designated           Residents matched by/for other specialists. The resident is designated as having a permanent position after completing the
                                           preliminary year(s).

C         Categorical                      Positions for residents who begin and remain in a given program or specialty until completion of the year(s) required for admission
                                           to specialty board examination.

CB        Combined                         Each resident participating in a combined specialty track is counted as 0.5 FTE and the total number of positions will/should be
                                           rounded up to the nearest whole number




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B.   Anticipated Duty Hours

     For the previous four week period:                                                            Yr 1   Yr 2   Yr 3   Yr 4
     Excluding call from home, what will be the average number of hours on duty per resident per
     week?
     Excluding call from home, what will be the maximum number of continuous hours worked by
     any resident?
     On average, how many days per week of in-house call will residents be assigned?
     On average, how many days for an entire four week period will each resident have completely
     free from all educational and clinical responsibilities?
     On average, how many hours off duty will each resident have between duty shifts? (Duty
     shifts include in-house call, and conference.)




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                   RESIDENCY REVIEW COMMITTEE FOR EMERGENCY MEDICINE
                         515 N State, Ste 2000, Chicago, IL 60610  (312) 755-5028  www.acgme.org

                                     PROGRAM INFORMATION FORM (Part 2)

                                           FOR NEW APPLICATIONS ONLY

SECTION 4. BACKGROUND INFORMATION
A.   Program Format

     Indicate the program format by checking the description of your program. (Check only one.)

     ( ) Accredited Length: 3 Years, Prior Training Required: 0
     ( ) Accredited Length: 3 Years, Prior Training Required: 1
     ( ) Accredited Length: 4 Years, Prior Training Required: 0

B.   Format Support

     Provide details below to support the program format.

     1.   Does the program require additional years of training for which it has not received accreditation?   YES ( ) NO ( )

          If YES, please explain.




E.   Goals of Education

     Include written goals of education.




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SECTION 5. INSTITUTIONS
A.   Letters of Support

     1.   Submit letters of support from the following officials: (Insert as Appendix P.R. II.A, B).

          Dean of the Medical School (if affiliated)
          Chief Executive Officer of the primary clinical training site

     2.   Submit letters of support from the Chief of Services for the following: (Insert as Appendix P.R. II.C, D, E, F)

          Chief of Service for Internal Medicine
          Chief of Service for Trauma Surgery
          Chief of Service for Pediatrics
          Chief of Service for Obstetrics/Gynecology
          Chief of Service for Orthopaedic Surgery

B.   Affiliation Agreements (See P.R. II.A)

     1.   Medical School Affiliation(s)

          Insert Letter of Affiliation with each medical school (Insert as Appendix P.R. II.A).

     2.   Participating Institution Affiliations (See P.R. II.B)

          For each participating institution to which residents rotate provide a written letter of understanding or affiliation
          agreement that governs the relationship between the institutions. New program applicants must submit copies of all
          affiliation agreements.

          Provide a letter of understanding (or memoranda) signed by the individual responsible for each resident rotation
          (excluding electives) in the program. This letter must be signed by the Program Director (Insert as P.R. II.B). Include
          clinical rotation summaries to describe:

          a.   The location, year of training, and duration of the rotation
          b.   A statement outlining educational objectives
          c.   The clinical and didactic experiences used to meet those objectives
          d.   The feedback mechanisms and methods used to evaluate the performance of the resident
          e.   A description of the resources and facilities in the institution that will be available to each resident, including but
               not limited to library and medical records;
          f.   A description of the clinical experiences, duties and responsibilities the resident will have on the rotation;
          g.   A description of the relationship that will exist between emergency medicine residents and the residents and
               faculty on the service
          h.   A description of the supervision emergency medicine residents will receive on the rotation.
          i.   A description of the work hours that residents will have on the rotation.
          j.   A statement that the rotation summary has been reviewed and agreed to by the service director

C.   Participating Institutions (See P.R. II.C)

     1.   Will more of the total clinical experience occur at the primary clinical site than any other single training site?
                                                                                                                      YES ( ) NO ( )

          If NO, please explain and insert as P.R. II.C.2.

     2.   Will any of the regular planned didactic or laboratory instruction occur outside of the primary clinical site?
                                                                                                                      YES ( ) NO ( )

          If YES, please list the site(s) and the distance(s) from the primary clinical site (in miles) and the approximate travel
          time (in minutes). Also list the percent of conferences to be conducted at outside sites. Insert as P.R. II.C.3.




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D.   Facilities and Resources (See P.R. II.D)

Institution Name

Please DUPLICATE this page to provide the following information in full for each institution with an Emergency Department to
which residents rotate. Differentiate each institution on a separate page. If additional space is needed for responses then
insert and label each attachment by institution name and status (Primary or Participating. (Insert as P.R. II.C.4, 5, etc.)

1.   Describe the location, size, and character of the patient care space in the Emergency Department (one area or divided
     areas) including: the specific location and access route to the Emergency Department, the number of square feet of
     patient care, administrative, and conference space; the total # of patient care beds; please specify the # of critical care
     beds and the # of observation beds. Please include a scale diagram of the Emergency Department (P.R. II.D.1) Drawing
     may not exceed 8 x 11". Insert as Primary Clinical Site: (name) or Participating Institution: (name). Highlight the area(s) for
     which the emergency department has control and indicate whether there is a fast track/urgent care area.

2.   Indicate the turnaround times for the following:

     Item                                                               Turnaround time
     0 Negative or type specific uncrossmatched blood
     ABGs
     Electrolytes

3.   Specifically state time to obtain results for CT of the head and portable chest x-ray.

     CT of Head Time:                                     Portable Chest X-Ray Time:

5.   Describe the location and size of the administrative space for the Program Director, the faculty, and the residents.




6.   Insert the complete bibliography of the medical reference resources, both print and digital, available within the clinical
     Emergency Department. Include the date of publication for print materials. Do not include references in the medical school
     library or faculty offices.




7.   Does the ED have internet access for use by residents and faculty?                                            YES ( ) NO ( )

8.   Describe security support services available to the Emergency Department.




9.   How are the following financed?

     a.   Emergency Department operating budget




     b.   Emergency Medicine Core faculty salaries




     c.   Emergency Medicine resident salaries




     d.   Emergency Medicine fellow salaries




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E.   Clinical Services

     Are all clinical specialties and subspecialty services available to the ED for consultation and admission 24/7?
                                                                                                                  YES ( ) NO ( )

     If not, provide the written hospital policy regarding how these services will be provided for emergency patients.




F.   Emergency Department Patient Flow

     1.   What is the average throughput time (entry to leaving the ED) for admitted patients in the main ED (excluding urgent
          care)?




     2.   What is the average throughput time for discharged patients (entry to leaving the ED)?




     3.   What is the average number of hours each month the hospital/ED is on ambulance diversion?




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SECTION 6. TEACHING STAFF/PERSONNEL (See P.R. III.A)
A.   Head of Emergency Medicine

     1.   Is the department chair/chief a member of the program’s core teaching faculty?                       YES ( ) NO ( )

     2.   Is the department chair/chief an experienced administrator in emergency medicine?                    YES ( ) NO ( )

          Briefly describe that experience.




     3.   Does the department chair/chief have appropriate authority and responsibility for the care of patients in the
          Emergency Department?                                                                         YES ( ) NO ( )

          To what individual(s) does the department head directly report regarding patient care issues?




          (Please insert copies of both the institutions and the Emergency Departments administrative organizational charts.)

     4.   Are these any areas in the Emergency department that do not operate under the control of the department head?
                                                                                                             YES ( ) NO ( )

          If YES, please explain.




     5.   Describe the method in which disputes over Emergency Department admissions are settled.




     6.   Does the department chair/chief participate in institutional policy-making?                          YES ( ) NO ( )

          If YES, how?




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B.   Program Director (Insert full Curriculum Vitae as P.R. III.B)

Name:                                                                Academic Rank:
Institution:
ABEM Certification:                                                  Year of most recent certification:
Certificate #:
Other ABMS/AOA Specialty Certification:                              Year of most recent certification:
Medical School:                                                      Year of Graduation:

POSTGRADUATE TRAINING

                       Institution                                     Specialty                          Dates (From - To)




EMPLOYMENT HISTORY FOLLOWING GRADUATION

                  Institution/Location                                 Position                           Dates (From - To)




Note: If Program Director is not based at the primary clinical site as indicated in Part 1, Section 2, provide explanation as
Attachment P.R. III. B.1)

PROGRAM DIRECTOR’S RESPONSIBILITIES (P.R. III.C)

Appointment of Residents                                                                                            YES ( ) NO ( )

Assignment of Residents                                                                                             YES ( ) NO ( )

Supervision of educational activities                                                                               YES ( ) NO ( )

Evaluation of Residents                                                                                             YES ( ) NO ( )

Input into the evaluation of Faculty                                                                                YES ( ) NO ( )




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C. Teaching Staff and Core Program Faculty (see P.R. III.D)

Please provide the following information for all core faculty physicians.

DUPLICATE THIS PAGE AS NEEDED. DO NOT SUBMIT CURRICULUM VITAE. THESE WILL BE DISCARDED.

Name:                                                                       Academic Rank:
Institution*:
ABEM Certification:                                                         Year of most recent certification:
Certification #:
Other ABMS/AOA Specialty Certification                                      Year of most recent certification:
Medical School:                                                             Year of Graduation:
* Name of institution of primary clinical responsibility.

POSTGRADUATE TRAINING

                       Institution                                      Specialty                         Dates (From - To)




EMERGENCY MEDICINE EMPLOYMENT AFTER COMPLETION OF RESIDENCY

Institution/Location                                        Position                              Dates (From - To)




a.   Insert (P.R. III.D) a list of current professional activities/committees/society memberships (specific to EM).

b.   Insert (P.R. III.D) a list of scholarly activities over the past five years including: peer review articles, textbook chapters,
     other non-peer reviewed publications, abstracts , visiting professorships, scientific presentations at national meetings, and
     editorial review services to professional publications or organizations.

c.   Insert an individualized job description for this faculty member. Use Institution numbers from Part 1, Section 2.

Hours per Week Spent in:                                    Institution 1     Institution 2       Institution 3    Institution 4
Clinical Supervision
Administration
Research
Didactics/Teaching




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D.   Other Attending Staff (See P.R. III.F)

Provide the following information for each of the emergency medicine non-core faculty participating in the training of residents
in the program in all EDs where residents rotate.

DUPLICATE THIS PAGE AS NEEDED. DO NOT ATTACH CVS. DO NOT LIST "BOARD ELIGIBLE." IF AN INDIVIDUAL IS A
RECENT EMERGENCY MEDICINE RESIDENCY GRADUATE WHO HAS YET TO TAKE THE BOARDS, LIST “EM TRAINED”
UNDER ABEM COLUMN. IF AN INDIVIDUAL IS CERTIFIED BY AN ABEM SUB-BOARD, LIST THE BOARD AND YEAR
UNDER ABEM COLUMN.

                                                Most Recent Certification Date
                                                                               Years of EM
Name                                             ABEM (List      Other (List                               Institution
                                                                               Experience
                                                   Year)          Specialty)




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E.   Core Faculty Development (see P.R. III.E)

Describe the faculty development opportunities that are available to the faculty.

P.R. III.E:




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Summary of Core Faculty

                                                                                                                                                     National/
                                             Board    Faculty    Clinical Super-   Administra-                     Teaching/                                          Editorial
                                     Res.                                                           Research                              Non-       Regional
          Name               Pos              Cert.   Years in        vision          tion                         Didactics      Peer                                Review
                                     Trng.                                                         (Hrs/Week)                             Peer     Presentations
                                             (Year)     EM         (Hrs/Week)      (Hrs/Week)                     (Hrs/Week)                                          Services
                                                                                                                                                      (5 Yrs)




Pos - Administrative Position (e.g., P.D.).
Res. Trng. - Type of Residency Training.
Board Cert. (yr) -Specialty Board and most recent year of certification.
Peer - Peer-reviewed Articles or case reports accepted or published within the past 5 years.
Non-Peer - Non-Peer reviewed articles, case reports or book chapters accepted or published within past 5 years.
National or regional presentations - Invited presentations at regional or national meetings, visiting professor presentations, etc. Do not list presentations within one’s own
    institution
Editorial Review - Editorial board service, reviewer for peer-reviewed journals, peer reviewer for academic or grant-awarding organizations




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F.   Support Personnel (See P.R. III.F)

     This page should be duplicated for each Emergency Department to which residents rotate and for separate sub areas of
     the same Emergency Department when those areas function independently (adult, pediatric, psychiatric emergency,
     urgent care, observation unit, etc.).

     Institution:
     Sub Area:

     Indicate the departments (or sub areas) total number of full-time equivalents of the following nonphysician Emergency
     Department personnel.

     Personnel                                                     Number of Personnel
     Nurses
     Midlevel providers (NP’s or PA’s)
     EM Technicians
     Clerical
     Orderlies/Aides
     Other (specify)

     1.   Indicate approximate turnaround time for an ECG.

     2.   Indicate approximate response time for respiratory therapy.

     3.   Do residents routinely draw blood?                                                              YES ( ) NO ( )

          If YES, please explain.




     4.   Do residents routinely transport noncritical patients?                                          YES ( ) NO ( )

          If YES, please explain.




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SECTION 7. PATIENT POPULATION (See P.R. IV.A.I)
A.   Patient Population Statistics

     If more than 4 Emergency Departments are used, copy this page, renumber the institutions and insert.

     For the most recent 12-month period                 From:                                To:

                                                           Institution 1
                           Statistics                                         Institution 2       Institution 3      Institution 4
                                                             (Primary)
     a.   Total ED Patients*
     b.   % of ED pediatric patients**
     c.   % of ED adult patients

     * Include only patients evaluated and treated in the ED.
     ** Ages 0 - 18 Years.

        Total Number of ED Patients by Clinical            Institution 1
                                                                              Institution 2       Institution 3      Institution 4
                     Conditions                              (Primary)
     a. Trauma
     b.   Surgical (non-trauma)
     c.   Medical
     d.   Obstetrical/Gynecological
     e.    Psychiatric

                                                                    Institution 1
                                Statistics                                          Institution 2    Institution 3    Institution 4
                                                                      (Primary)
     Percentage of patients hospitalized following treatment in
     ED (excluding ED observation units)
     Percentage of ED patients admitted to CRITICAL CARE
     units following treatment (excluding observation and step
     down units)
     Percentage of ED patients taken directly to the operating
     suite following treatment
     Number and % of deaths in ED*                                           %                %               %                %
     Percentage of ED patients primarily assessed and treated
     by EM residents
     Percentage of ED patients primarily assessed and treated
     by EM faculty
     Percentage of ED patients primarily assessed and treated
     by non EM residents
     Percentage of ED patients primarily assessed and treated
     by non EM faculty
     Percentage of ED patients primarily assessed and treated
     by physician extenders (PAs and NPs)

     * Include only patients on whom resuscitation was attempted.




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B.   Supervision (See P.R. IV.A.2)

     This page should be duplicated for each Emergency Department to which residents rotate and for separate sub areas of
     the same Emergency Department when those areas function independently (adult, pediatric, psychiatric emergency,
     urgent care, observation unit, etc.).

     Institution #1:
     Sub Area:

     Annual Patient Volume in Sub Area

     1.   Will residents be supervised by Emergency Medicine faculty at all times in the area?              YES ( ) NO ( )

          If NO, please insert explanation as IV.A.2.a.




     2.   Are these faculty qualified, as required in P.R. III.D.2.1?                                       YES ( ) NO ( )

          If NO, please explain:




     3.   Will EM faculty ever provide supervision from outside the area?                                   YES ( ) NO ( )

          If YES, please explain.




     4.   How many EM faculty hours of on-line supervision per day will be provided in the area?

     5.   Does this coverage change on weekends?                                                            YES ( ) NO ( )

          If YES, please specify.




     6.   Will supervision provided be commensurate to each resident's level of training?                   YES ( ) NO ( )

     7.   Do residents from other services receive supervision from Emergency Medicine faculty when rotating in the area?
                                                                                                              YES ( ) NO ( )

          If NO, please explain.




     8.   Will the presence of other residents diminish the opportunity for responsibility by senior emergency medicine
          residents?                                                                                     YES ( ) NO ( )

          If YES, how?




     9.   In each month of the most recent academic year specify the number of residents from other specialties, other EM
          residents from other programs, and fellows assigned to the ED .

                 Month       Other Specialty Residents (Non-EM)         Fellows         Residents from other EM Programs
          July
          August


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                Month        Other Specialty Residents (Non-EM)          Fellows           Residents from other EM Programs
          September
          October
          November
          December
          January
          February
          March
          April
          May
          June

     10. Will EM Residents rotating on non-EM services be provided supervision equivalent to that provided in ACGME-
         approved residencies in those specialties?                                                  YES ( ) NO ( )

          If NO, please explain.




C.   Progressive Responsibility (See P.R. IV.A.3)

     Describe how responsibilities of Emergency Medicine residents will differ at each level of training relative to supervision,
     clinical responsibilities, teaching and administration. How many hours of overlap will exist between junior and senior
     Emergency Medicine residents daily in the Emergency Department? If this pattern varies among the participating
     Emergency Departments, please explain.




D.   Presence of other Residences and Other Educational Resources (See P.R. IV.A.5)

     Provide the following information for residents training in other ACGME specialties at the primary care site and at
     participating institutions as specified on Part 1 Section 2. Insert additional pages, if necessary.

                                                                     ACGME Accreditation Status*
         Name of Training Program
                                              Institution 1         Institution 2          Institution 3        Institution 4




     *Accreditation Categories: PV = Provisional,
                                CV = Continued Provisional,
                                FA = Full Accreditation or Continued Full Accreditation,
                                PR = Probation,
                                CR = Continued Probation,
                                WD = Withdrawn.




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E.   Fellowships (See P.R. IV.A.6)

     Does the program offer any Emergency Medicine related fellowships?                                                                                   YES ( ) NO ( )

     If YES, please complete the following:

     Type of fellowship:
     Duration of Training:
     Number of fellowship positions offered:

     Describe the fellows’ clinical responsibilities and their overall impact on the programs educational needs.




     List all fellows currently in training.

                                                                                                                                                         Duration of
                                                                         Type of Previous Residency                                                      Fellowship
     Name and Degree                            Type of Fellowship                                         Board Certification (Y, N) and Board Name
                                                                                   Training
                                                                                                                                                       Begins    Ends




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F.   Resident Duty Hours (See P.R. IV.A.7) I

     1.   Will residents assigned to the ED have one day in seven free of any clinical or academic responsibilities at each level
          of training?                                                                                           YES ( ) NO ( )

          If NO, please explain.




     2.   Will residents ever work longer than 12 continuous scheduled hours in the Emergency Department? YES ( ) NO ( )

          If YES, please explain.




     3.   Between scheduled work periods (including any call activities) will there always be at least an equivalent period of
          continuous scheduled time off?                                                                      YES ( ) NO ( )

          If NO, please explain.




     4.   Will residents work more than 60 scheduled hours per week seeing patients in the Emergency Department?
                                                                                                           YES ( ) NO ( )

          If YES, please explain.




     5.   Will residents be assigned any program related activities that total more than 72 duty hours per week while on
          emergency medicine rotations?                                                                   YES ( ) NO ( )

          If YES, please explain.




     6.   Will residents have appropriate duty hours when rotating on other clinical services, in accordance with the ACGME-
          approved program requirements for each specialty?                                                   YES ( ) NO ( )

          If NO, please explain.




     7.   Will residents have shifts assigned in the Emergency Department while rotating on other services?     YES ( ) NO ( )

          If YES, please explain.




     8.   Will the program monitor activity outside the residency that may interfere with the resident's performance as defined
          in the agreement between the institution and the resident?




          Insert the program's policy on resident participation in activities outside the residency, such as
          moonlighting. Insert as IV.A.7.h (1)

     9.   How are faculty and residents educated to recognize the signs of fatigue?




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     10. Will residents moonlight in-house?                                                YES ( ) NO ( )

          If so, what will be their role in the Emergency Department while moonlighting?




          Will they give or receive supervision when moonlighting?




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SECTION 8. BLOCK CATEGORICAL EMERGENCY MEDICINE ROTATION
Following the format below, provide a block diagram of a typical resident's educational experience. It is understood that the actual experience of some individual residents
may vary somewhat from the schedule documented here. Within each block, indicate as part of the table the rotation length/responsible department, If rotations are
scheduled by months, use blocks 1 - 12. If rotations are scheduled as weeks, use blocks 1 - 13 (each block = 4 weeks).

        Year - 1               1           2       3          4           5          6           7          8           9          10         11          12         13
Primary Site #1
Institution #2
Institution #3
Institution #4


        Year - 2               1           2       3          4           5          6           7          8           9          10         11          12         13
Primary Site #1
Institution #2
Institution #3
Institution #4


        Year - 3               1           2       3          4           5          6           7          8           9          10         11          12         13
Primary Site #1
Institution #2
Institution #3
Institution #4


        Year - 4               1           2       3          4           5          6           7          8           9          10         11          12         13
Primary Site #1
Institution #2
Institution #3
Institution #4




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SECTION 9. CONFERENCES (See P.R. IV.B.2-4.)
1.   Will the program offer its residents an average of at least 5 hours per week of planned educational experiences developed
     by the Emergency Medicine residency program?                                                               YES ( ) NO ( )

2.   What is the seating capacity of the instructional setting where the EM didactic conferences will be held?

3.   How often will residents be precluded from attending conferences by their clinical duties?

4.   Will this change depending on the year of training? If YES, please describe.                                YES ( ) NO ( )

5.   On which rotations will residents be precluded from attending conferences by their clinical duties?




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SECTION 10. CURRICULUM - GOALS AND OBJECTIVES (See P.R. IV.B.5-6)
A.   Procedures (See P.R. IV.B.5-6)

     Calculate the average number of the following procedures that will be performed by residents in your program during
     training. The site visitor will confirm the accuracy of this data.

     Procedure                                                                Performed on Patients   Performed in Lab
     1.   Cardiac pacing (either transvenous or transcutaneous)
     2.   Central Venous Access
     3.   Chest Tube Insertion
     4.   Conscious Sedation
     5.   Cricothyrotomy
     6.   Dislocation Reduction
     7.   Emergency Bedside Ultrasound
     8.   Endotracheal Intubation
     9.   Lumbar Puncture
     10. Pericardiocentesis
     11. Peritoneal lavage
     12. Splinting
     13. Thoracotomy
     14. Vaginal Delivery

     Explain the method by which the above numbers of procedures were derived. Please note: Records documenting the
     method will be reviewed by the site visitor.




B.   Patient Follow-up (See P.R. IV.B.8)

     Explain how program will teach the importance of patient follow-up:




C.   Supervision - Educational Experience (See P.R. IV.B.3)

     Will at least 50% of the total educational experience for residents take place under the supervision of Emergency
     Medicine faculty?                                                                                   YES ( ) NO ( )

     If NO, please explain.




D.   Out of Hospital Care (See P.R. IV.B.11)

     1.   Will the program offer a paramedic base station experience?                                     YES ( ) NO ( )

     2.   Will the program require a structured EMS rotation?                                             YES ( ) NO ( )

     3.   Will residents ride with ground units?                                                          YES ( ) NO ( )

     4.   Will residents have the opportunity to ride with air ambulance units?                           YES ( ) NO ( )

     5.   Will residents participate in teaching prehospital personnel?                                   YES ( ) NO ( )

     6.   Will residents participate in disaster planning and drills?                                     YES ( ) NO ( )



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     7.   Will residents participate in prehospital care quality assurance audits?                              YES ( ) NO ( )

     8.   Will EM faculty teach/supervise EMS to EM residents?                                                  YES ( ) NO ( )

     9.   What will be the average number of hours of EMS conferences held each year?

     10. What will be the average number of base station runs directed by a resident during training?

     11. What will be the average number of hours spent by each resident in riding with ground units during training?

     12. Will residents be required to ride in ground or air ambulance units?                                   YES ( ) NO ( )

          If yes, will they be notified of this at the time of application?                                     YES ( ) NO ( )

E.   Major Resuscitations (See P.R. IV.B.11)

     Each resident must have sufficient opportunities to perform invasive procedures, monitor unstable patients, and direct
     major resuscitations of all types on all age groups. A major resuscitation is patient care for which prolonged physician
     attention is needed and interventions such as defibrillation, cardiac pacing, treatment of shock, intravenous use of drugs
     (e.g., thrombolytics, vasopressors, neuromuscular blocking agents), or invasive procedures (e.g., central line insertion,
     chest tubes, endotracheal intubation) are necessary for stabilization and treatment. The resident must have the
     opportunity to make admission recommendations and direct resuscitations.

     Estimate the average number of major resuscitations (as defined in Program Requirement IV.B.12.) to be directed by
     residents by the time of graduation. The site visitor will confirm the accuracy of this data and documentation will be
     reviewed. Only the resident acting as leader of the resuscitation may count the experience as a major resuscitation. Other
     EM residents present may not count this as a major resuscitation.

                       Type of Resuscitation                                         Number of Resuscitations
     Adult Medical and Nontraumatic Surgical
     Adult Trauma
     Pediatric Medical*
     Pediatric Trauma*
     Total

     * Ages 0 - 18 years.

     Explain the method by which the above numbers of resuscitations were derived.




F.   Core Competencies

     1.   Describe how your program will teach system-based practice and performance improvement.




     2.   Describe how your program will teach and evaluate professionalism.




     3.   Describe how your program will teach and evaluate ethics.




     4.   Describe how your program will teach and evaluate interpersonal skills and communication skills.




2a9f6b94-28a9-4609-a842-473f5109020e.doc
     5    Describe how your program will teach and evaluate continued incorporation of new medical knowledge into medical
          practice.




     6    Describe how your program will teach and evaluate recognition of medical errors and continued practice based
          learning that allows residents to incorporate these concepts in future practice.




     7    Competencies Specific to Emergency Medicine

          a.   Annual Competency Assessment – Describe the Program’s measurable competency objectives for each year of
               training. How will these objectives be measured? How will deficiencies be remedied?




          b.   Chief Complaint Competency – Describe how your program will teach and assess competencies for three chief
               complaints germane to emergency medical practice.




          c.   Procedural Competency – Describe how your program will teach and assess competencies for three procedures
               (such as the ones listed in PIF Section 10.A).




          d.   Resuscitation Competency – Describe how your program will teach and assess competencies for one type of
               resuscitation (as described in PIF Section 10.G.).




          e.   Off-Service Rotations – Describe the Program’s measurable competency objectives for at least half the
               program’s off service rotations. (You may refer to the specific clinical rotation summaries (PIF Section 5.B.2., if
               this information is described there.)




G.   Research Education (See P.R. IV.B.13)

     Will residents be taught basic research methodologies, statistical analysis and critical analysis of current medical
     literature?                                                                                          YES ( ) NO ( )

     If NO, please explain.




     How many hours will be devoted to this endeavor annually?

H.   Pediatric Emergency Medicine (See P.R. IV.B)

     1.   Does the program offer a specific pediatric emergency department experience?                           YES ( ) NO ( )

     2.   Will residents routinely direct pediatric resuscitations?                                              YES ( ) NO ( )

     3.   Will residents routinely perform invasive procedures (e.g., airway management techniques)              YES ( ) NO ( )

     4.   How many hours of didactics dedicated to pediatric emergency education are scheduled for the residents?




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     5.   Who will direct pediatric EM conferences (i.e., EM faculty, PEDS faculty, Fellows, etc.)?

     6.   What opportunities will be provided to residents to gain experience in pediatric sedation and pain management
          techniques?




     7.   What mechanisms will be available for residents to provide follow-up on pediatric EM patients?




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SECTION 11. EVALUATION
A.   Evaluation of Residents (See P.R. V.A)

     1.   Will the Program Director or faculty member designated by the program meet with each resident at least
          semiannually to conduct a formal, documented evaluation of his/her performance?        YES ( ) NO ( )

          If NO, please explain.




     2.   Will permanent records be maintained for each resident documenting his/her progress through training?
                                                                                                              YES ( ) NO ( )

     3.   Will there be documentation of each resident's management of patients with emergency conditions, to include:

          Major trauma resuscitations                                                                        YES ( ) NO ( )

          Medical resuscitations                                                                             YES ( ) NO ( )

          Pediatric resuscitations                                                                           YES ( ) NO ( )

          Performance of emergency procedures                                                                YES ( ) NO ( )

          Will these be formally reviewed with each resident during the semi-annual evaluation?              YES ( ) NO ( )

     4.   Will there be documentation of oral examinations?                                                  YES ( ) NO ( )

     5.   Will there be documentation of written examinations?                                               YES ( ) NO ( )

     6.   Will semi-annual evaluations be signed by the residents?                                           YES ( ) NO ( )

B.   Evaluation of Faculty (See P.R. V.B)

     1.   Are individual faculty members formally evaluated by the head of Emergency Medicine at least annually?
                                                                                                             YES ( ) NO ( )

     2.   Is there documentation that written summaries of evaluations have been communicated to faculty members?
                                                                                                           YES ( ) NO ( )

     3.   Will the residents have systematic, formal written opportunities to evaluate the faculty?          YES ( ) NO ( )

     4.   Describe the mechanism used for preserving resident confidentiality in the evaluation process.




     5.   Describe the Program Director's role in the evaluation of faculty.




     6.   Do the faculty evaluations include documentation of:

          a.   Teaching ability;                                                                             YES ( ) NO ( )

          b.   Clinical knowledge;                                                                           YES ( ) NO ( )

          c.   Administrative and interpersonal skills;                                                      YES ( ) NO ( )

          d.   Scholarly contributions?                                                                      YES ( ) NO ( )

               If the answer is NO for any of the above, please explain.




2a9f6b94-28a9-4609-a842-473f5109020e.doc
C.   Evaluation of the Program (See P.R. V.C)

     1.   Will there be an annual evaluation of the entire program?                                           YES ( ) NO ( )

     2.   Will the annual evaluation include a section on curriculum?                                         YES ( ) NO ( )

     3.   Will the annual evaluation include a section on clinical rotations?                                 YES ( ) NO ( )

     4.   Will the evaluation process provide for resident participation?                                     YES ( ) NO ( )

     5.   Will residents use the rotation summaries to assess the effectiveness of the rotations in accomplishing their stated
          objectives?                                                                                         YES ( ) NO ( )

          If NO, explain.




          If the answer is NO for any of the above, please explain.




D.   Due Process

     Are there due process procedures applicable to resident and faculty evaluations and grievances? (The site visitor will
     review the procedures.)                                                                             YES ( ) NO ( )




2a9f6b94-28a9-4609-a842-473f5109020e.doc
                   RESIDENCY REVIEW COMMITTEE FOR EMERGENCY MEDICINE
                         515 N State, Ste 2000, Chicago, IL 60610  (312) 755-5028  www.acgme.org

                                           PROGRAM INFORMATION FORM
Checklist

             Requirement II - Letters of Support
             Requirement II.A - Letter of Affiliation Agreement with Medical School (For medical schools not previously
             approved)
             Requirement II.B - Letters of Understanding and/or Affiliation Agreements (For institutions not previously approved
             by the RRC)
             Requirement II.D.1 - Diagram of Emergency Department
             Requirement II.D.5 - Bibliography of Medical Reference Resources (Emergency Department)
             Requirement III. Institution / Emergency Department Organizational Charts
             Requirement III.B - Program Director CV / and List of Activities for previous 13 months
             Requirement III.B.1 - Explanation for Program Director who is not based at primary clinical site.
             Requirement III.D - Teaching Staff
                  Current Professional Activities/Committees/Society Memberships (specific to EM)
                  List of Scholarly Activities, Peer Review Publications, and/or Textbook Chapters
             Requirement III.E - Development Plan (Core Faculty)
             Requirement IV.B.1 - Clinical Rotation Summaries
             Policy Statement for Resident Participation in activities outside the Emergency Department (P.R. IV.A.7.c)
             List of Scholarly Activities (Resident Participation)
             Report of Resident’s Performance on Part I and Part II of the Certifying Examination (ABEM)
             Due Process Procedures (Resident and Faculty)
             General Competencies Addendum to the PIF




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