RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS
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RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS Document Transcript

  • PEDIATRIC GASTROENTEROLOGY 9/03 RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 N. State St., Suite 2000 Chicago, IL 60610 INSTRUCTIONS FOR COMPLETING PROGRAM INFORMATION FORMS FOR PROGRAMS IN PEDIATRIC GASTROENTEROLOGYThe same program information form (PIF) is used for those making initial application and thoseundergoing periodic re-review.Applications: The RRC will evaluate an application for a new program without a prior site visit. Contact the RRC office for deadlines. Note that a subspecialty program must function in conjunction with a fully accredited program in pediatrics that is in good standing.Title: The title of a subspecialty program should correspond to the title of the affiliated pediatrics program to facilitate cross referencing.Sponsor: Identify as the SPONSORING INSTITUTION that entity which has final administrative responsibility for the program, as evidenced by the fact that it monitors the quality of the education and coordinates the accreditation activity. This must be the same sponsor as the core pediatrics residency. If the SPONSORING INSTITUTION and the PRIMARY HOSPITAL are one and the same, the hospitals name should be entered in both sections.Before work is begun on this form, the Program Requirements for Subspecialties of Pediatricsand the Program Requirements for Residency Education in Pediatric Gastroenterology shouldbe thoroughly reviewed. Copies of these documents may be obtained from the ACGMEwebsite (www.acgme.org).If more than one hospital participates in the program, information on each hospital should begiven as requested. The program director is responsible for gathering the requested datafrom the participating institutions and consolidating the information on one form.The total length of time subspecialty residents are assigned to each participating hospitalshould be filled in as requested on Pages 1 and 2.
  • -2-If the subspecialty residents in your program rotate for a period of time to another accreditedpediatric gastroenterology program, the written agreement should include: 1) the scope of theaffiliation; 2) the resources in the affiliated program which will be available to the subspecialtyresidents; 3) the duties and responsibilities the subspecialty residents will have in the affiliatedprogram; 4) the relationship which will exist between subspecialty residents and staff of theaffiliate and primary programs.For those sections where additional pages are needed to answer the questions, retype eachquestion using a small bold type font and answer in a larger font. It is important that theoriginal pagination remain the same. If necessary, paginate the forms by hand in the upperright corner.All sections of the form must be completed. If any requested information is not available, anexplanation should be given in the appropriate place on the form. The completed form shouldbe prepared as a single document with all added pages numbered in sequence as requested.INCLUDE ONLY THE REQUESTED INFORMATION.The program director is responsible for the accuracy of the information supplied in this formand must sign it. It must also be signed by the Department Chair/Chief of Service and theDesignated Institutional Official of the sponsoring institution.ALL PAGES INCLUDED IN THE FORM SHOULD BE 8 1/2" BY 11". DO NOT USEUNDERSIZED OR OVERSIZED SHEETS. Each copy of the completed form may be securedwith a rubber band, a clip, or it may be loosely enclosed in protective materials. DO NOTpunch holes in the form. Remove all staples within the form, e.g., from the CVs. DO NOT useany kind of process to bind the form or attach it to anything. DO NOT insert section dividers.The number of copies to be submitted will vary as follows:New application: Send four complete copies to the Executive Director of the Residency Review Committee for Pediatrics at the above address.Resurvey: See letter announcing the site visit.If you have questions about the form, contact the Accreditation Administrator (Phone:312-755-5044). For word processing questions/problems, contact the ACGME Help Desk(Phone: 312-755-7464). For questions regarding a site visit, contact the writer of the letterannouncing the survey.H:pedspif-pd332pif02.doc
  • 9/03 RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS 515 North State Street, Suite 2000, Chicago, Illinois 60610 PROGRAM INFORMATION FORM PEDIATRIC GASTROENTEROLOGYDATE OF APPLICATION:TITLE OF PROGRAM:(Use first line of program listing on the ACGME Website for core Pediatrics program to which this program is attached.New Application: ( ) Accredited Program: ( )Pediatric Gastroenterology Program Director Full Time: YES NONAME:Title:Address:E-mail Address:Telephone: Fax:The signatures of the director of the program and the chief of the department attest to the completeness and accuracy of the informationprovided on these forms.Signature - Pediatric Gastroenterology Program Director Signature - Chief of Pediatrics/Department ChairmanSPONSORING INSTITUTION: (Name the entity, i.e., the university, hospital, or foundation that has administrative responsibility for this program.)Name of Sponsor:Address:Name of Designated Institutional Offiicial (Typed):Signature:If this is not a medical school program, is there an affiliation with a medical school: YES NOIf yes, name the medical school and append a document that specifically describes the effects of these arrangements onthis program. Label this Appendix C.Name of Medical School:
  • 2PRIMARY HOSPITAL (Hospital 1)Name:Address: City/State/ZIP:Total number of months pediatric gastroenterology trainee is 1st year 2nd year 3rd yearassigned to this institution in each year of training:Chief/Chair, Department of Pediatrics:For each participating institution provide letters of agreement specifying the administrative and organizationalrelationships which bear upon the educational program. Attach as Appendix C.OTHER PARTICIPATING INSTITUTION (Hospital 2)Name:Address: City/State/ZIP:Total number of months pediatric gastroenterology trainee is 1st year 2nd year 3rd yearassigned to this institution in each year of training:Distance between 2 and 1 in Miles: In Minutes:Is this hospital used for: (check Required Elective Other?appropriate box) rotations? rotations?Chief/Chair, Department of Pediatrics:OTHER PARTICIPATING INSTITUTION (Hospital 3)Name:Address: City/State/ZIP:Total number of months pediatric gastroenterology trainee is 1st year 2nd year 3rd yearassigned to this institution in each year of training:Distance between 3 and 1 in Miles: In Minutes:Is this hospital used for: (check Required Elective Other?appropriate box) Rotations? rotations?Chief/Chair, Department of Pediatrics:
  • 3 DURATION OF TRAININGThe program requirements which were approved by the ACGME on February 16, 1993, contain the following paragraphregarding the duration of training:Two years of progressive educational experience is required, which includes the development of procedural skills,responsibility for patient care and participation in research. Any program that extends training beyond the minimumrequirements must present clear educational rationale consonant with the Program requirements and objectives forresidency training. The program director must obtain approval of the Residency Review Committee prior toimplementation and at each subsequent review of the program. Prior to entry in the program, each resident must benotified in writing of the required length of training.If you propose or offer a program of three years duration, please provide the educational rationale below. In doing so,make reference to both the Program requirements for Pediatric Gastroenterology and the Program Requirements forSubspecialties of Pediatric Programs.
  • 4 SUBSPECIALTY RESIDENTSPrograms making initial application should provide ONLY THE INFORMATION marked by an asterisk (*) in thetop section of the of this page:*Number of positions offered: Year 1 Year 2 Year 3Number of positions filled: Year 1 Year 2 Year 3*Source of salary support for % from NIH: % from other non-federal % from hospital:subspecialty residents: (Add programs:the salaries of allsubspecialty residents andindicate what percent of thetotal is supplied by each ofthe following services:) % from other federal % from practice-generated % from other: programs: income:*Does the program have a funded training grant? *If yes, YES NOsupply the following: *If yes, supply the following:*Grant: *Amount *Project Director: CURRENT SUBSPECIALTY RESIDENTSProvide the following information regarding the current subspecialty residents in the program: Date began Name of ACGME- Name gastroenterolog accredited pediatric Date of Date of y program residency program completion Name of medical graduation completed school GRADUATES OF THE PROGRAM Total number of graduates of the program in the last five years:Provide the following information regarding the subspecialty residents who have completed the program in the last five years. Useadditional pages as necessary, numbered 4a, 4b, etc. Include name, present location, present position, type of practice, if sub-board certification in pediatric gastroenterology has been achieved.
  • PROGRAM FACULTY Program Requirements for Subspecialties of Pediatrics, IV Program Requirements Pediatric Gastroenterology, VA. PROGRAM DIRECTOR Explain how the program director meets the Program requirements with regard to: a) Board and Sub-board certification; b) demonstrated competence as a teacher and researcher; and, c) Adequate administrative experience to direct the program. If not certified by the American Board of Pediatrics Sub-board of Pediatric Gastroenterology, provide evidence of equivalent qualifications. Use an additional page numbered as page 5a to include your answer. Do not exceed one page.B. FACULTY List below the faculty members who are direct contributors to the program, including the program director. List the gastroenterologists first. Time on gastroenterology teaching service should include the total of time spent providing instruction, supervising inpatient and outpatient experiences and supervising consultation experiences. Also include and identify any research mentors who participate in training. Duplicate this page if necessary. Time on gastroenterology Certification teaching service Name Primary specialty Location: Hospital 1, 2, 3 Hrs. per week Wks. per year Pediatrics Recertification Specify other (yr.) (yr.) board & yearFor each of those listed above, provide details of the individuals role in the pediatric gastroenterology training program. If not certified in pediatric gastroenterology, provideevidence of equivalent qualifications. Specify the type of contact with the subspecialty residents, e.g., lectures, group discussions, ward rounds, laboratory supervision, patientcare activities, consultations. Indicate clearly how the reported time is distributed. Include research mentors. Use additional pages as needed, numbered as 5b, 5c, etc.C. CURRICULUM VITAE 1. Attach as Appendix A the program directors full curriculum vitae and complete bibliography of articles in peer-reviewed journals. 2. For faculty members listed on the chart above, other than the program director, attach curriculum vitae using the CV format contained on the page identified as Appendix B at the end of this form and follow its instructions. 5 4
  • PROGRAM FACULTY (Continued)D. PROGRAM STAFF: RELATED SPECIALISTS (working with pediatric gastroenterology) at participating hospitals: Complete the following chart using the name of the primary staff member involved. It is understood that certification is not available in all of the disciplines listed below. Faculty hours reported should be only for hours CONTRIBUTED TO THIS PROGRAM. Use 40 hours per week as the full time equivalent. Numbers of additional faculty in each field should be entered in the last column. (If adult specialists cover pediatric subspecialties, enclose name or number in parentheses.) Sub-certification/ Faculty participation Discipline Name Recertification in training program Hospital 1, 2 or 3 No. of other faculty Name of Year of Hours Weeks Sub-board certification/ per per recertification week year Neonatology Pediatric Hematology/Oncology Pediatric Allergy/Immunology Genetics Pediatric Infectious Diseases Pediatric Surgery Pediatric Anesthesiology Pediatric Pathology Pediatric Radiology Child Psychiatry and/or Psychology Nutrition Other: (specify)If any of the above are not housed predominantly in the primary hospital, provide specific details of their availability to the program. Include on a page numbered 6a. 6
  • 7PROGRAM FACULTY (Continued)D. PROGRAM STAFF: OTHER ANCILLARY STAFF List only the numbers of those who work in the pediatric gastroenterology training program: Hospital 1 Hospital 2 Hospital 3 Nurse specialists and/or physician extenders in gastroenterology Pediatric social workers Pediatric nutritionists Other (specify):Describe the involvement of the staff in each of these categories in the pediatric gastroenterology program:
  • 8 FACILITIES AND SERVICES Program Requirements Pediatric Gastroenterology, IVIndicate the availability of the following: Hospital 1 Hospital 2 Hospital 3 Facility/Service Yes No Yes No Yes No Space in an ambulatory setting for optimal evaluation and care of patients An inpatient area with pediatric and related services (including surgery and psychiatry) staffed by pediatric residents and faculty Support services including radiology laboratory, nuclear medicine and pathology Pediatric intensive care unit Number of beds in PICU Neonatal intensive care unit Number of beds in NICU Access to gastrointestinal function laboratory capable of measuring intestinal absorptive function, esophageal physiology and pancreatic function and nutritional parameters in pediatrics patients Flexible endoscopy facilitiesProvide an explanation if NO is indicated for any of the above facilities and/or services across all hospitals:
  • 9 PATIENT DATAProvide the following information for the most recent 12-month period. Inclusive dates: FROM (mm/dd/yy): TO (mm/dd/yy): INPATIENT 1. Total number of admissions for whom the pediatric gastroenterology service assumed major clinical responsibility: a. Average daily census of patients on the pediatric gastroenterology service If ADC is less than six, please explain how residents have an adequate exposure to inpatients on a page numbered 8a. b. Number of new patients admitted each year ("new" refers to those who are being seen by the gastroenterologists for the first time): c. Average length of stay of patients on the pediatric gastroenterology service: 2. Number of consultations by pediatric gastroenterologists on other inpatients: a. Are consultations provided to the NICU? YES NO If yes, how many? b. Are consultations provided to the PICU? YES NO If yes, how many?
  • 1AMBULATORY PEDIATRIC GASTROENTEROLOGY EXPERIENCE FOR ALL YEARS OF TRAINING Number of Number of Average Number of New Patients Return Average Number Duration of Sessions Per Per Patients Per Number Teaching Name of Experience Experience Week Per Resident resident Other Trainees Attendings Faculty Hospital/Other Setting Identifier (in wks/yr) Resident Per Session Per Session Per Session Per Session Supervision S Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N1. If the experience is in a private office, provide full details, including name and credentials of supervisor, numbers and types of patients, degree of residentresponsibility for their care, frequency of attendance at office, how director monitors the experience and resident performance. Include as pages 10a, 10b, etc.2. Explain how the residents have the opportunity to provide outpatient care for patients whom they treated on the inpatient service. 10
  • 11 12-MONTH SUMMARY: OUTPATIENT CLINICS/INPATIENT SERVICESDuring the same 12-month period as used on page 9, how many pediatric patients with the following gastroenterology problemswere: a) seen in the ambulatory settings; b) were admitted to and/or consulted on by the pediatric gastroenterologists at theprimary hospital? PROGRAMS MAKING NEW APPLICATION SHOULD COMPLETE ONLY THE COLUMNS MARKED BYAN ASTERISK ( * ). Inclusive Dates: FROM (mm/dd/yy): TO (mm/dd/yy): Gastroenterology Outpatients Inpatients problems Number of Number seen by Inpatient service Consultations patients* subspecialty residents No. on No. seen by No. of No. seen by gastro subspecialty consults* sub-specialty service* residents residents 1. Growth failure and malnutrition 2. Malabsorption (celiac disease, cystic fibrosis, pancreatic insufficiency, etc.) 3. Gastrointestinal allergy 4. Peptic ulcer disease 5. Jaundice 6. Liver failure (including evaluation and follow-up care of patient requiring liver transplantation) 7. Digestive tract anomalies 8. Chronic inflammatory bowel disease 9. Functional bowel disorders 10. Gastrointestinal problems in the immune-compromised host 11. Vomiting (including gastroesophageal reflux) 12. Acute and chronic abdominal pain 13. Acute and chronic diarrhea 14. Constipation (including Hirshsprung disease) 15. Gastrointestinal bleeding 16. Gastrointestinal infections 17. Motility disorders 18. Infectious and metabolic liver diseases 19. Pancreatitis
  • 12 LIST OF DIAGNOSESList 150 CONSECUTIVE admissions and/or consultations from the general pediatric service to the gastroenterology serviceduring the same 12-month period as used on the previous pages. Use additional pages as necessary. Submit a separate listfor each hospital that provides required rotations. Number all additional pages in sequence as 12a, 12b, etc. Hospital: Inclusive dates during which these FROM (mm/dd/yy): TO (mm/dd/yy): admissions/consultations occurred: PATIENT ID NUMBER OF DAYS IN HOSPITAL GASTROENTEROLOGIC DIAGNOSIS NUMBER AGE
  • SKILL OBJECTIVES Program Requirements Pediatric Gastroenterology, II.CIndicate whether or not the program provides experience in each of the following procedures. Use the same 12-month period as indicated on the previous pages. Forprocedures not performed at any of the participating hospitals, provide an explanation on a page numbered 13a. PROGRAMS MAKING NEW APPLICATIONCOMPLETE ONLY THE COLUMN MARKED "NUMBER PERFORMED ON SERVICE(S)" FOR EACH HOSPITAL. Inclusive Dates: FROM (mm/dd/yy): TO (mm/dd/yy): Hospital 1 Hospital 2 Hospital 3 Number Total # Number Total # Number Total # performed performed by performed performed by performed performed by on sub-specialty on sub-specialty on sub-specialty service(s) residents service(s) residents service(s) residents 1. Colonoscopy 2. Diagnostic upper panendoscopy 3. Establishment and maintenance of patients on enteral/parenteral nutrition (including nutritional assessment) 4. Sigmoidoscopy (rigid and flexible) 5. Paracentesis 6. Percutaneous liver biopsy 7. Rectal biopsy 8. Small bowel biopsy 9. Anorectal manometry 10. Breath hydrogen analysis 11. Dilatation of esophagus 12. Endoscopic retrograde cholangiopancreoscopy (ERCP) 13.Therapeutic upper pandendoscopy (sclerosis of esophageal varices) 14. Esophageal manometry 15. Pancreatic stimulation test 16. Esophageal pH monitoring 17. Placement of percutaneous gastrostomy 13
  • CONTENT OF TRAINING PROGRAMComplete the following chart by providing the duration of the activities specified below for each year of the training program. Answers should be provided as indicated, i.e., inmonths, in weeks, or in other appropriate time periods. First Year Second Year Third Year (if offered) 1. Clinical training months months months Frequency of night call Number of clinical rounds per week per week per week 2. Research training and experience months months months Frequency of night call 14
  • 15 CONFERENCES Program Requirements Pediatric Gastroenterology, II.DList regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the pediatric gastroenterology trainingprogram. Identify the INSTITUTION by using the corresponding number as it appears on the first and second pages of this form.Indicate the frequency, e.g., weekly, monthly, etc., and whether conference attendance is required (R) or optional (O). Person(s) responsible for conducting Hospital 1, Conference R, O Frequency conference 2, or 3Describe how subspecialty residents participate in these activities:What are the attendance requirements for subspecialty residents? What mechanisms are (will be) used to ensure trainee attendance atrequired conferences? To what degree is faculty attendance expected? Is this monitored?
  • 16 NARRATIVE DESCRIPTIONProvide a narrative description of this subspecialty program. The points listed below should be covered in the narrative.A. PROGRAM GOALS AND OBJECTIVES (Program Requirements for Subspecialties of Pediatrics) 1. Describe the educational goals and objectives of the program. 2. Are the goals and objectives documented in writing and available for review? Are they provided to the resident? 3. Describe how the goals and objectives are reviewed and revised. Describe the role of the resident and the faculty in this process.B. RELATIONSHIP TO OTHER PROGRAMS 1. What are the differences in responsibilities for the subspecialty residents at each level of training from those of the pediatric residents? 2. How are patients assigned or apportioned between the pediatric residents and those in this subspecialty program? 3. How are those in this subspecialty program involved with other pediatric subspecialty residents, other clinics, departments and accredited residency programs?
  • 4. How are the subspecialty residents involved in the education of pediatric residents and medical students?C. SPECIALTY EXPERIENCES (Refer to the requirements and describe how they are covered in the program) 1. Provide a general description of each year of training. 17 2. Inpatient experiences a. What responsibilities do the subspecialty residents have for inpatients requiring acute and chronic care in appropriate facilities when assigned to inpatient services? b. How and by whom are they supervised? c. How many hours per week do they participate in rounds with faculty? Describe this experience. 3. Outpatient experiences a. What degree of responsibility do the residents have for required outpatient care?
  • b. Describe the continuity of care experience they receive during their period of assignment to the outpatient clinic. To what extent do they have the opportunity to provide outpatient care for patients whom they treated on the inpatient service? c. How and by whom are they supervised during the provision of outpatient care? d. How do subspecialty residents have the opportunity to provide outpatient care for patients whom they treated on the inpatient service? 4. Other a. Describe any special sessions/coursework/special laboratory experiences in which the residents participate. 18 b. How are psycho-social aspects of medicine and ethical issues related to this subspecialty taught to the residents? c. Describe the residents instruction and experience in the administration of a pediatric gastroenterology facility.D. RESEARCH PROGRAM (Program Requirements for Subspecialties of Pediatrics, V)
  • 1. Is the program director directly involved in a research program?2. Are other faculty in this subspecialty actively engaged in a research program?3. How does the program ensure a meaningful supervised research experience for the residents, beginning in their first year and extending throughout their training? Include a description of how they learn experimental design, data collection and analysis, and laboratory techniques used in this subspecialty research. Include the plans for frequency and duration of these sessions and the year of training in which they occur. Identify the teacher/supervisor in each case.4. How do they receive support and guidance in the preparation of manuscripts and presentations?5. Describe research facilities, space and equipment directly related to this subspecialty program and the residents research activity.6. List active research projects in this subspecialty. Include the title of the project, the principal investigator(s), and the amount, dates and source(s) of financial support.
  • 19 7. Provide a list of scholarly publications and presentations at regional, national and international meetings by faculty and residents within the program for the last five years only. Do not duplicate citations. Underline the names of subspecialty residents. List journal articles, presentations and abstracts separately under those headings.E. SERVICE DUTIES (Program Requirements for Subspecialties of Pediatrics, III) Describe the call schedule including whether it is on-site or from home. Demonstrate how the schedule allows the subspecialty residents a monthly average of one day in seven away from program duties.F. LIBRARY FACILITIES (Program Requirements for Subspecialties of Pediatrics, VII) Describe the library facilities and their availability to the residents. How is the library equipped to handle the particular needs of pediatric subspecialists? Are there computerized literature search facilities available?G. EVALUATION (Program Requirements for Subspecialties of Pediatrics, VIII) Do not attach evaluation forms but have them available for inspection by the site visitor. 1. Evaluation of subspecialty residents a. How often and by whom are the residents in this program formally evaluated? Are written records of the evaluations maintained by the program? b. Describe the process, frequency and by whom these evaluations are discussed with the residents. c. Do they have an opportunity to read and respond to their evaluations? Describe the process.
  • 20 d. Describe the mechanisms for monitoring each residents acquisition of skills in the performance of the procedures utilized in this subspecialty.2. Evaluation of faculty a. Describe the mechanism, frequency and by whom faculty are evaluated on their teaching ability, clinical knowledge and scholarly activity. b. How do the residents in this training program participate formally in the process?3. Evaluation of program by staff and residents? a. Is the training program periodically evaluated by the staff and the residents? b. How often does this evaluation take place and what is the mechanism by which it is accomplished?
  • c. How are these evaluations used in program planning and development?
  • Appendix B CURRICULUM VITAE CV should be condensed to fit this page. Do not add additional pages except as directed below.Append bibliography for the past FIVE YEARS ONLY, limited to articles published or in press and abstracts presented. Name Position: Address: Professional education (including dates and degrees obtained): Hospital training (including dates of internships, residencies, fellowships, etc.) Current professional appointments: Primary certification (including date): Subspecialty certification (including date): Recertification (including date): Professional activities/committees:
  • RESIDENCY REVIEW COMMITTEE FOR PEDIATRICS PEDIATRIC GASTROENTEROLOGY Program Information Form ChecklistUse this checklist before submitting the forms to the RRC office. The RRC considers it the responsibilityof the program director to ensure that the application materials are complete and are submitted inaccordance with the instructions. The signature of the program director on the forms indicates his/herapproval of the content. A review of the instructions provided at the beginning of the form and onindividual pages is suggested._______ Have the appropriate person(s) signed page 1 of the forms where requested?_______ Is the form free of unrequested schedules, printouts, reprints, catalogues, brochures, etc?_______ Do the CVs attached as Appendix A follow appropriate instructions regarding their length?_______ Are all requested official letters of agreement/affiliation appended as requested on pages 1 and 2?_______ Has the final copy been carefully proofread and has it been checked to see that everyquestion has been answered, every chart completed, etc.?_______ Has the ACGME letter of report regarding the Institutional Review of the Sponsoring Institution been appended?Once the preparer is satisfied that the form has been completed and assembled correctly, make theappropriate number of copies. After the copies have been made, review the individual sets to besure that all of the copied pages are legible and that each set of forms contains all of the pages in theoriginal. ALL PAGES INCLUDED IN THE FORM SHOULD BE 8-1/2” BY 11.” DO NOT USEUNDERSIZED OR OVERSIZED SHEETS. The completed copies of the form may be secured withone large clip or enclosed in a folder. DO NOT STAPLE. Holes should not be punched in the formand it should not be attached to the folder.
  • CONTENTS PROGRAM NAME: PROGRAM #:Retain our pagination followed through the form, e.g., 8, 8a, 8b, etc. When you finish, go through the form, number each page sequentiallywith black ink or typed in upper right hand corner. Report this pagination on this page. Place this page at the front of the form. SECTION IN PROGRAM INFORMATION FORM Page Number(s) 1. Training Sites Sponsoring Institution Participating Institutions 2. Pediatric Gastroenterology Residents 3. Program Faculty A. Program Director B. Faculty C. Curriculum Vitae (Appendices A & B) D. Program Staff 4. Facilities and Services 5. Patient Data Inpatient Service Ambulatory Experience 6. 12 Month Summary: Outpatient Clinics/Inpatient Services 7. List of Diagnoses 8. Skill Objectives 9. Content of Training Program 10. Conferences 11. Narrative Description of the Pediatric Gastroenterology Program A. Program Goals and Objectives B. Relationship to Other Programs C. Specialty Experiences D. Research Program E. Service Duties F. Library Facilities G. Evaluation 12. Appendices Appendix A (Program Director’s Full CV) Appendix B (Teaching Staff CV’s) Appendix C (Letters of Agreement)