Clinical Training Setting Information (Form E)
www.abgc.net




Instructions: Please submit one form for each distinct cli...
Clinical Training Setting Information (Form E)
www.abgc.net




5.    In this clinic, the number of patients or families w...
Clinical Training Setting Information (Form E)
www.abgc.net




       List Staff Name      ABMG, ABGC or CCMG
       unde...
Clinical Training Setting Information (Form E)
www.abgc.net




      Molecular Genetics:
                                ...
Clinical Training Setting Information (Form E)
www.abgc.net




                  




      (3)   Detail other activities...
Clinical Training Setting Information (Form E)
www.abgc.net




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Instructions: Please submit one form for each distinct ...

  1. 1. Clinical Training Setting Information (Form E) www.abgc.net Instructions: Please submit one form for each distinct clinical type/setting* at which any of your students may obtain clinical experience. A separate form must be completed for each clinical setting, even when several settings are located at the same clinic site.** Each setting should have a unique sequential number, i.e., the “P number,” that corresponds to the program, site, and setting, respectively. The P number, along with the names of the site and setting, will be used for reference and should correspond to the master list of clinical sites on Form D. Information about the setting must accurately reflect the staffing, supervisors, and level of trainee involvement at the time the form is completed. If submitting this application as part of a program’s accreditation (including provisional accreditation) and the site is approved, the program’s trainees may use cases obtained in the site beginning January 31st of the year it is approved. This form can also be used to apply for a clinical placement that was not submitted or approved as part of the program’s accreditation/provisional accreditation; if the site is approved, the program’s trainees may use cases seen in this setting from the date the application was received. Terminology: Clinical setting* refers to the specific clinic or service, e.g., prenatal diagnosis, hemoglobinopathy clinic, inpatient consultation, etc. Clinic site** refers to the physical and institutional location of this setting, usually a medical center, university, or private office. Application: Training Site Information: Site and Setting Number: P      -      -       1. Name of training program/institution submitting form:       2. Clinic site:       3. Clinic address: City:             State:       Zip code:       4. Clinical type/setting [choose the one which best describes this clinic]: General genetics Pediatric genetics Prenatal diagnosis General genetics Pediatric genetics Prenatal diagnosis Metabolic or Molecular diagnostic Hematology endocrine Neurogenetic Neurocutaneous Neuromuscular MR/developmental Craniofacial Skeletal Teratogen service Outreach/satellite Other: Cancer
  2. 2. Clinical Training Setting Information (Form E) www.abgc.net 5. In this clinic, the number of patients or families with which a genetic counseling trainee would be sufficiently involved to obtain an ABGC logbook case during this rotation is:       6. How many total weeks does a student spend in this clinical setting?       7. Duration of a typical clinic: Full day Half day Other, e.g., consultation service 8. The number of genetic counseling trainees who would typically be involved in this clinical setting at the same time, i.e., on the same day, is:       9. Does this clinic utilize non face-to-face counseling, e.g., Yes No telemedicine or telephone? 10. If the answer to question 9 is Yes, then list the number of non face-to-face counseling cases with which the trainee would be sufficiently involved to obtain an ABGC logbook case during this rotation:       [Note: A total of five (5) non face-to-face cases can be utilized per logbook.] 11. Does the program wish to use this clinical setting for acquisition of logbook cases? Yes No Don’t know 12. Does this clinical setting currently have logbook approval? Yes P       -       -       No 13. List the names and ABMG/ABGC/CCMG certification status of genetics personnel who supervise genetic counseling students in this clinical setting. If a staff member’s name has changed: include his/her last name at the time of certification in parentheses ( ) next to his/ her current name. (Please see next page)
  3. 3. Clinical Training Setting Information (Form E) www.abgc.net List Staff Name ABMG, ABGC or CCMG under Area(s) of Certified?* Role in Clinic Specialty Yes/Year No Clinical Genetics:                                                                                           Genetic Counseling:                                                                                                                                                                   Biochemical Genetics:                                    
  4. 4. Clinical Training Setting Information (Form E) www.abgc.net Molecular Genetics:                                     Cytogenetics:                                     Ph.D. Medical Genetics:                                     * Note: Primary care Canadian geneticists certified by either the Royal College of Physicians and Surgeons (FRCPC) or the Quebec College of Physicians and Surgeons (CSPQ or SCPQ) are also eligible to provide clinical supervision. 14. Indicate which of the following logbook roles would be fulfilled by the student over the course of this clinical placement: Case preparation Discussion of diagnosis and natural history Contracting Discussion of testing options/results Eliciting of medical history Psychosocial assessment Pedigree Psychosocial support/counseling Risk assessment Resource identification/referral Inheritance/risk counseling Follow-up 15. Nature of Clinical Experience and Supervision [for Reaccreditation only]: For a previously approved clinical setting, how has the nature of this setting changed since its previous approval? Yes No 16. Describe the nature of the experience a trainee would have over the course of this clinical placement. [Note: This description section is optional for previously approved sites of a program undergoing Re-accreditation.] Include full responses to the following; use a separate sheet of paper if necessary. (1) What proportion of the trainee's involvement is likely to be participatory as opposed to observational?       (2) How is the trainee's involvement documented, e.g., chart notes, pedigree, psychosocial reports, etc.?
  5. 5. Clinical Training Setting Information (Form E) www.abgc.net       (3) Detail other activities that will be required during the placement, e.g., patient management conferences, journal club, etc.       (4) How will the trainee participate in the activities listed in (3)?       (5) How and by whom is in-clinic supervision provided?       17. We verify† that the information describing this clinical setting experience is correct, and that we have agreed to accept counseling students from ________ ______________ [name of program] as trainees in our clinic. We will support their clinical training by providing participatory learning experiences under our direction and supervision. ________________ ________________ _________ Medical Director of Clinic† (Type/Print Name) (Signature) (Date) (dd/ mm/yy) Supervising Genetic ________________ ________________ _________ Counselor† (Type/Print Name) (Signature) (Date) (dd/mm/yy) ________________ ________________ _________ Supervising Geneticist† (Type/Print Name) (Signature) (Date) (dd/mm/yy) Program Director or ________________ ________________ _________ Designee † (Type/Print Name) (Signature) (Date)
  6. 6. Clinical Training Setting Information (Form E) www.abgc.net (dd/mm/yy) † This sheet must always be signed by the clinic director; if cases are to be used in the logbook, the certified geneticist and genetic counselor who will provide clinical supervision must also sign this sheet. For a setting to be approved either an ABGC/ABMG certified genetic counselor or an ABMG/CCMG certified geneticist must routinely provide supervision. Primary care Canadian geneticists certified by either the Royal College of Physicians and Surgeons (FRCPC) or the Quebec College of Physicians and Surgeons (CSPQ or SCPQ) are also eligible to provide clinical supervision.

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