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    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - CLINICAL NEUROPHYSIOLOGY GENERAL INSTRUCTIONS APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with the Web Accreditation Data System). 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. Once the forms are complete, number the pages sequentially in the bottom center. Send three complete copies to the executive director of the Residency Review Committee for Neurology at the address above. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding. The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution. Review the Program Requirements for Residency Education in Clinical Neurophysiology. The Program Requirements or the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org): For questions regarding: -the completion of the form (content), contact the Accreditation Administrator. -the Accreditation Data System, email WebADS@acgme.org. For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp Clinical Neurophysiology i
    • Attach the following documents to the application: References to Common Program and Institutional Requirements are in parentheses The Designated Institutional Official should provide the following: 1. Policy for supervision of fellows (addressing fellow responsibilities for patient care, progressive responsibilities for patient management, and faculty responsibility for supervision) (CPR VI.B) 2. Program policies and procedures for fellows’ duty hours and work environment, including grievance and due process (CPR VI; IR II.D.4.e.; IR II.D.4.i.; IR III.B. 3.) 3. Moonlighting policy (CPR VI.E) 4. Documentation of monitoring of fellow duty hours to determine compliance with the requirements (CPR VI.C.1-3) 5. Documentation of internal review (date, participants’ titles, type of data collected, and date of review by the GMEC) (IR IV.) 6. Current Program Letters of Agreement (PLAs) (CPR I.B.1) The Program Director should provide the following: 1. Document delineating the eligibility criteria to enter the program (CPR III.A) 2. Document delineating the skills and competencies the fellow will be able to demonstrate at the conclusion of the program (CPR IV.A.1) 3. Evaluations: a) Objective assessments for the six competencies (Patient Care, Medical Knowledge, Practice- based learning & improvement, Interpersonal & Communication Skills, Professionalism, Systems- based Practice) showing input from multiple evaluators (faculty, peers, patients, self, and other professional staff) (CPR V.A.1.b.(1) and (2)) b) Documentation of fellows’ semiannual evaluations of performance with feedback (CPR V.A.1.b.(3)) c) Final (summative) evaluation of fellows, documenting performance during the final period of education and verifying that the fellow has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2) d) Documentation of program evaluation and written improvement plan (CPR V.C) 4. Files of current fellows and most recent program graduates Single Program Sponsors only, attach the following additional documents to the application: 1. Copy of the institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2) 2. Copy of the fellow contract with the pertinent items required by the Institutional Requirements highlighted and numbered according to the Institutional Requirements (IR II.C-D). 3. Institutional policy for recruitment, appointment, eligibility, and selection of fellows (IR II.A) 4. Institutional policy for discipline and dismissal of fellows (IR III.B.7) Clinical Neurophysiology ii
    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org 10 Digit ACGME Program I.D. #: Program Name: TABLE OF CONTENTS When you have completed the forms, number each page sequentially in the bottom center. Report this pagination in the Table of Contents and submit this cover page with the completed PIF. Common PIF1 Page(s) Accreditation Information Participating Sites Single Program Sponsoring Institutions (if applicable) Faculty/Resources Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty Roster Program Resources Fellow Appointments Number of Positions Actively Enrolled Fellows (if applicable) Skills and Competencies Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Specialty Specific PIF Page(s) Site Directors Fellows Clinical Neurophysiology Fellows Other Clinical Neurophysiology Fellows Other Fellows In Training Clinical And Educational Facilities and Resources Facilities Supporting Facilities Educational Program Curriculum Basic and Clinical Neurophysiology Sciences Instruction and Lectures Clinical and Basic Science Clinical Teaching – Outpatient Clinical Neurophysiology EEG/EMG/Sleep Outpatient Diagnostic Categories Outpatient Specialty Clinics Educational Program Research and Scholarly Activity Fellow Meeting Attendance Clinical Neurophysiology iii
    • Specialty Specific PIF Page(s) Fellow Research Projects Fellow Publications Evaluation Fellow Evaluation Impaired Fellows Fellow Stress Appendix A - Written Goals and Objectives by Rotation Clinical Neurophysiology iv
    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - CLINICAL NEUROPHYSIOLOGY A. ACCREDITATION INFORMATION Date: Title of Program: Core Program Information Title of Core Program: Core Program Director: 10 Digit ACGME Program ID#: Accreditation Effective Date: Status: Next Review Last Review Date: Cycle Length: Date: The signatures of the director of the program 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 Core Program Director (and Date): Signature of Designated Institutional Official (DIO) (and Date): 1. Respond to previous citation(s) Provide a concise update on each previous citation and indicate how each has been addressed (if applicable). 2. Describe changes not mentioned above Provide a concise update explaining any major changes, not described in your response to question # 1, to the fellowship program since the last site visit (for example, changes in program format, fellow complement, program leadership, or participating sites). 3. Planned start date for the first class of fellows (answer only if this is a new application) Clinical Neurophysiology 1
    • B. PARTICIPATING SITES SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NO City, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Name of Designated Institutional Official: Mailing Address: Phone Number: Email: Name of Chief Executive Officer: PRIMARY SITE (Site #1) Name: Address: City, State, Zip Code: Clinical Site? ( ) YES ( ) NO Type of Rotation (select one) Elective ( ) Required ( ) Both ( ) Length of Fellow Rotations (in months) CEO/Director/President’s Name: Joint Commission Accredited? ( ) YES ( ) NO If no, explain: The Program Director must submit any participating sites routinely providing an educational experience, required for all fellows, of one month full time equivalent (FTE) or more. Duplicate as necessary. PARTICIPATING SITE (Site #2) Name: Address: City, State, Zip Code: Integrated: ( ) YES ( ) NO Does this site also sponsor its own program in this subspecialty? ( ) YES ( ) NO Does it participate in any other ACGME-accredited programs in this ( ) YES ( ) NO subspecialty? Distance between #2 & Miles: Minutes: #1: Type of Rotation ( ) Elective ( ) Required ( ) Both (select one) Length of Fellow Rotations (in months) CEO/Director/President’s Name: Brief Educational Rationale: Clinical Neurophysiology 2
    • 1. Single Program Sponsoring Institutions (Institutions that sponsor a single core or subspecialty program, or a single core program and its subspecialties). For those institutions which are either a single-program sponsoring institution (e.g., medical genetics only), or an institution with multiple residencies accredited by the same Residency Review Committee (RRC), the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions. a) Provide an institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2) b) Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how fellows and faculty in the program are involved in the evaluation process. (CPR V.C; IR IV) c) Describe how the institution complies with the Institutional Requirements regarding “Resident Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of fellows in accordance with the Program and Institutional Requirements. (IR II.A-B) d) Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the fellow contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the fellow contract/agreement to the PIF but state when it is given to the fellows and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.) (IR II.C-D) e) Describe in detail the grievance (due process) procedure(s) that is available to fellows, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a fellow’s contract, or other actions that could significantly threaten a fellow’s intended career development. (IR II.D.4.c-d) Clinical Neurophysiology 3
    • C. FACULTY / RESOURCES 1. Program Director Information Name: Title: Address: City, State, Zip code: Telephone: FAX: Email: Date First Appointed as Program Director: Principal Activity Devoted to Fellow Education? Yes: No: Term of Program Director Appointment: Date first appointed as faculty member in the program: Number of hours per week Director spends in: Clinical Administration: Research: Didactics/Teaching: Supervision: Primary Specialty Board Certification: Most Recent Year: Subspecialty Board Certification: Most Recent Year: Number of years spent teaching in this subspecialty: a) Is the program director familiar with and does he/she oversee compliance with ACGME/RRC policies and procedures as outlined in the ACGME Manual of Policies and Procedures (found at http://www.acgme.org/acWebsite/about/ab_ACGMEPoliciesProcedures.pdf)? .....................................................................................................................( ) YES ( ) NO b) Using the form provided in section C.3. provide a one page CV for the program director. Clinical Neurophysiology 4
    • 2. Physician Faculty Roster List alphabetically and by site all physician faculty who devote at least 10 hours a week to resident education. Using the form provided below, supply a one page CV for each faculty listed. Primary and Secondary Specialties / Average Hours Per Week Spent On: Fields Years as Based Board Most Recent Faculty Name Primarily Specialty Certification Certification in Clinical Didactic (Position) Degree at Site # / Field (Y/N)† Date Specialty Supervision Admin Teaching Research (PD) † Certification for the primary specialty refers to ABMS Board Certification. Certification for the subspecialty refers to ABMS sub-board certification. Clinical Neurophysiology 5
    • 3. Faculty Curriculum Vitae First Name: MI: Last Name: Present Position: Graduate Medical Education Program Name(s); include all residencies and fellowships: Certification and Re- Certification Information Current Licensure Data Certification Re-Certification Date of Expiration Specialty Year Year State (mm/yyyy) Academic Appointments - List the past ten years, beginning with your current position. Start Date (mm/ End Date yyyy) (mm/yyyy) Description of Position(s) Present Concise Summary of Role in Program: Current Professional Activities / Committees: Selected Bibliography - Most representative Peer Reviewed Publications / Journal Articles from the last 5 years (limit of 10): Selected Review Articles, Chapters and/or Textbooks (Limit of 10 in the last 5 years): Participation in Local, Regional, and National Activities / Presentations - Abstracts (Limit of 10 in the last 5 years): If not ABMS board certified, explain equivalent qualifications for Review Committee consideration: 4. Non Physician Faculty Roster List alphabetically the non-physician faculty who provide required instruction or supervision of fellows in the program. # of Years Based Teaching as Primarily at Subspecialty / Role In Faculty in Name (Position) Degree Site # Field Program Subspecialty Clinical Neurophysiology 6
    • 5. Program Resources a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach fellows? Include time spent in activities such as conferences, rounds, journal clubs, research, mentoring, teaching technical skills etc. if relevant. b) Briefly describe the educational and clinical resources available for fellow education. [The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.] Clinical Neurophysiology 7
    • D. FELLOW APPOINTMENTS 1. Number of Positions (for the current academic year) Number of Requested Positions Number of Filled Positions* *Not applicable to new programs with no fellows on duty. Count part-time residents as 0.5 FTE. If the number of filled positions exceeds the number of positions approved by the Review Committee, provide an explanation of this variance. 2. Actively Enrolled Fellows (if applicable) a) List alphabetically all fellows actively enrolled in this program as of August 31 of current academic year. Has completed an ACGME- accredited specialty Program Expected Specialty of program Start Completion Year in Years of Most Recent (Y/N) If no, Name Date Date Program Prior GME Prior GME explain b) Did you obtain documentation that each fellow has met the eligibility criteria? ( ) YES ( ) NO Clinical Neurophysiology 8
    • RESIDENCY REVIEW COMMITTEE FOR NEUROLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - CLINICAL NEUROPHYSIOLOGY I. SITE DIRECTORS List the person responsible for supervising the fellow education activities of your program at each site. Site # Site Director 1. 2. 3. 4. Clinical Neurophysiology 9
    • II. FELLOWS (PR I) A. Clinical Neurophysiology Fellows What mechanism is there to ensure that the Program Requirement I.B.1 concerning prerequisite training is met? B. Other Clinical Neurophysiology Fellows List those clinical neurophysiology fellows who do not meet the ABPN’s preliminary training requirements before beginning the program. Year of Years of medical Expected Status Year in Type of prior Specialty of school Program completion in Name program position GME prior training Medical school graduation start date date program C. Other Fellows in Training List the graduate medical education (GME) residents (fellows) from other specialties who rotated through clinical neurophysiology during the last academic year. Clinical neurophysiology Specialty & years of GME Number of these residents in the Months each resident spent in assignment (EEG, EMG, (e.g. PGY-2 child) last year clinical neurophysiology sleep, other) Adult neurology PGY- Child neurology PGY- Neurosurgery PGY- Physical medicine & rehabilitation PGY- Psychiatry PGY- Other PGY- Clinical Neurophysiology 10
    • III. CLINICAL AND EDUCATIONAL FACILITIES AND RESOURCES (PR III) A. Facilities 1. Describe the physical facilities at each site for the clinical neurophysiology outpatient and inpatient evaluation and care of patients with seizure, neuromuscular, and sleep disorders. 2. Describe the availability of the office space at each site for faculty, clinical neurophysiology fellows, and support staff. 3. Indicate if the following office spaces and resources available. See the Common PIF for site numbers. Duplicate this section if more than 4 sites are used. Site Site #1 Site #2 Site #3 Site #4 Faculty office and facilities Are there offices for clinical neurophysiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO faculty? Is there secretarial office space for clinical ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO neurophysiology? Is there a departmental ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO library? Clinical neurophysiology fellow offices and resources Does each clinical neurophysiology fellow ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO have his/her own office? Are there offices for groups of clinical ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO neurophysiology fellows? Do the offices have computers and computer ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO internet search capabilities? Do the clinical neurophysiology fellows ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO have secretarial support? Do the clinical neurophysiology fellows have access to other office equipment such as ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO copiers, slide projectors, equipment or services to make slides, illustrations services? Clinical Neurophysiology 11
    • Site Site #1 Site #2 Site #3 Site #4 Do the clinical neurophysiology fellows ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO have access to major texts in the office? 3. Describe the clinical neurophysiology laboratory facilities at each site, including mechanisms for reporting of test results. 4. Describe clinical neurophysiology conference facilities at each site. 5. Describe the space provided for clinical neurophysiology faculty and clinical neurophysiology fellow research at each site. 6. Describe for each site how the charts or medical records are made available for inpatients, outpatients, and consultation use. B. Supporting Facilities Indicate whether the facilities and resources listed below are AVAILABLE for all participating sites listed in the Common PIF. If more than four sites, duplicate the section and include after this page. Diagnostic Resources Site #1 Site #2 Site #3 Site #4 Electroencephalography EEG ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Ambulatory EEGs ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Video-EEG monitoring ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Intraoperative ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO monitoring Electromyography: EMG/NCV ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Neuromuscular transmission testing ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO including single fiber studies Cranial nerve testing including blink ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO reflexes and facial nerve evaluation Sleep Lab: Polysomnography ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Multiple sleep latency ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Other clinical neurophysiology modalities: Evoked potentials ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Clinical Neurophysiology 12
    • Diagnostic Resources Site #1 Site #2 Site #3 Site #4 Visual ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Auditory ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Somatosensory ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Autonomic testing ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Movement disorder assessment with ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO botulinum toxin therapy Central EMG ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Magnetoencephalogra ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO phy Electroretinograms ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO (ERGs) Diagnostic ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO neuroimaging services MRI and MRA ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO CT ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO SPECT ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO PET ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Related diagnostic and therapeutic services: Cytogenetics and ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO genetic testing Genetic counseling ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO service Occupational therapy ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Pain management ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Adult rehabilitation ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO medicine Pediatric rehabilitation ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO medicine Physical therapy ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO Clinical Neurophysiology 13
    • IV. EDUCATIONAL PROGRAM A. Curriculum (PR V.A.) Describe in block and longitudinal templates the typical curriculum for clinical neurophysiology fellows. Curricular components may be offered in blocks or longitudinally. Those components offered in block assignments during this subspecialty year should be recorded in the block template by months, not weeks, including the site (#1,2,3,4) and the experience on each rotation. Clearly identify elective time. Exclude mention of vacation time. Obvious examples include EEG, EMG, Sleep, Seizure clinic, Neuromuscular clinic, etc. An example of longitudinal curriculum is a regularly scheduled clinical neurophysiology activity or clinic attended over a period of time while assigned to other rotations. Both longitudinal and block components can be applied toward FTE minimums described in the program requirements. For example, one half-day per week for ten months of a longitudinal clinic would count for one month FTE. SAMPLE BLOCK ROTATIONS - PG-2 July August September October November December January February March April May June Intro to Intro to EEG EEG EEG EEG Sleep Sleep EMG EMG EMG EMG CNP CNP Site 1 Site 1 Site 1 Site 3 Site 2 Site 2 Site 1 Site 1 Site 1 Site 1 Site 1 Site 1 SAMPLE LONGITUDINAL EXPERIENCES - PG-2 Type Of Experience* Weekly Structured Amount Of Time (FTE) EEG including adult and child 1/2 day each week 52 weeks EMG including adult and child 1/2 day each week 52 weeks Other Clinical neurophysiology One half day per week for 2 months Sleep One half day per week for 6 months Evoked Potentials One half day per week for 12 months Seizure Clinics BLOCK ROTATIONS – PG-1 YEAR IF THE PROGRAM IS A 4-YEAR PROGRAM July August September October November December January February March April May June LONGITUDINAL EXPERIENCES - PG-1 Type Of Experience* Weekly Structured Amount Of Time (FTE) Clinical Neurophysiology 14
    • B. Basic and Clinical Neurophysiology Sciences Instruction and Lectures 1. Basic science clinical neurophysiology curriculum 2. List of lectures, conferences, courses in applied clinical neurophysiology 3. List of neurology clinical conferences which the clinical neurophysiology fellow is expected to attend or participate in. 4. List of clinical courses, conferences and/or lectures given in the subspecialties of epilepsy, neuromuscular diseases, autonomic disorders, sleep, and vestibular disorders at each site. C. Clinical and Basic Science Site #1 Site #2 Site #3 Site #4 EEG Name of director(s) Number of studies per year EEG: adult/child Other Months fellows assigned Fellows’ responsibilities EMG Name of director(s) Number of studies per year EMG: adult/child Other Months fellows assigned Fellows’ responsibilities Sleep Name of director(s) Number of studies per year EMG: adult/child Other Months fellows assigned Fellows’ responsibilities Neuropathology Name of director(s) CNS surgical specimens per year Clinical Neurophysiology 15
    • Site #1 Site #2 Site #3 Site #4 Muscle biopsies Nerve biopsies Months fellows assigned Fellows’ responsibilities Autonomic Name of director(s) Number of studies per year EMG: adult/child Other Months fellows assigned Fellows’ responsibilities D. Clinical Teaching – Outpatient 1. Clinical neurophysiology fellow outpatient experience can include block time and longitudinal time in the outpatient clinics described under curriculum (V.A. above). For non-continuity and clinical neurophysiology related clinics, list the following as averages per fellow per clinic half-day: # New patients seen # Follow-up patients seen Staff/ fellow ratio 2. For the continuity seizure and/or neuromuscular longitudinal clinics, list the following as averages per fellow per clinic half-day. # New patients seen # Follow-up patients seen Staff/ fellow ratio 3. What is the role of the clinical neurophysiology fellow in the performance of and interpretation of clinical neurophysiology studies of adult patients? Clinical Neurophysiology 16
    • E. Clinical Neurophysiology EEG/EMG/SLEEP Diagnostic Categories Provide the number of patients in each of the following diagnostic categories that were available in the program for the past year. Each patient should be listed only once in the most appropriate category. Site #1 Site #2 Site #3 Site #4 Epilepsy (adult/child) Generalized Tonic-clonic Absence Myoclonic Localization-related Simple partial Complex partial Secondarily generalized Syncope Vasovagal Indeterminate spells Other alterations of consciousness Coma Motor unit disorders (adult/child) Motor neuron disorders Nerve root disorders Plexopathies Polyneuropathies Mononeuropathies Cranial nerve disorder Neuromuscular junction disorder Muscle disorder Dystrophies Congenital myopathies Channelopathies Inflammatory Sleep Disorders Dysomnias Obstructive sleep apnea Central sleep apnea Narcolepsy Periodic limb movements Parasomnias Autonomic Disorders (adult/child) Stroke related disorders Neoplastic disease Movement disorder Cognitive disorder Multiple Sclerosis Metabolic disorder Trauma Drugs and other toxic disorders Clinical Neurophysiology 17
    • Site #1 Site #2 Site #3 Site #4 Psychiatric disorders TOTAL F. Outpatient Specialty Clinics Site Site #1 Site #2 Site #3 Site #4 Specialty Clinics Clinic Name: Seizure Number of clinics per month Average number of visits per clinic Percent visits seen by clinical neurophysiology fellows Clinic Name: Neuromuscular Number of clinics per month Average number of visits per clinic Percent visits seen by clinical neurophysiology fellows Clinic Name: Sleep Number of clinics per month Average number of visits per clinic Percent visits seen by clinical neurophysiology fellows * If more specialty clinics need to be listed, attach as supplemental pages. G. Educational Program 1. What teaching responsibilities do clinical neurophysiology fellows have? (PR IV.C.II) 2. Outline fellow responsibility and frequency on night call at each site. 3. What provision is there to assure increasing patient responsibility and professional maturation of clinical neurophysiology fellows? (PR IV.) 4. Briefly describe how and when the following additional curricular areas taught (PR IV.) Medical Ethics Quality Assurance Health Care Organization, Practice Management Clinical Neurophysiology 18
    • Financing of Health Care Management Information Systems Clinical Neurophysiology 19
    • V. RESEARCH AND SCHOLARLY ACTIVITY (PR IV.C.10.) A. Fellow Meeting Attendance Provide a list of local, regional, and national neurological meetings that clinical neurophysiology fellows have attended over the past three years, showing the clinical neurophysiology fellows by name. B. Fellow Research Projects Describe the research projects, supervisors and their specialties, and the nature of the clinical neurophysiology fellows’ involvement in clinical neurophysiology research during the past five years. List by name those clinical neurophysiology fellows who participated in such research, the duration of their assignment, and whether full-time or part-time. C. Fellow Publications List the publications of clinical neurophysiology fellows from the clinical neurophysiology section/division during the past 36 months. (Do not include manuscripts submitted or in preparation) Clinical Neurophysiology 20
    • VI. EVALUATION A. Fellow Evaluation (PR III.A.2.g) 1. Does the faculty review a representative sample of the clinical neurophysiology fellow’s written patient records and reports?.......................................................................( ) YES ( ) NO 2. Does the program provide feedback to clinical neurophysiology fellow on audits of their written patient records? ( ) YES ( ) NO 3. Does the program perform a formal, observed clinical evaluation exercise (CEX) on clinical neurophysiology fellows at least once? ......................................................( ) YES ( ) NO 4. Describe the standardized methods for fellow evaluation used in the program (e.g., an in-service training exam). 5. Over the past 5 years what proportion of clinical neurophysiology fellows has taken these examinations? B. Impaired Fellows How does the program deal with impaired clinical neurophysiology fellows? C. Fellow Stress How does the does the program monitor clinical neurophysiology fellow stress, provide counseling and support services? Clinical Neurophysiology 21
    • APPENDIX A - GOALS AND OBJECTIVES FOR THIS CLINICAL NEUROPHYSIOLOGY RESIDENCY PROGRAM Clinical Neurophysiology 22