RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5027 • www.acgme.org PROGRAM INFORMATION FORM FOR CONTINUED ACCREDITATIONGENERAL INSTRUCTIONSREVIEW OF AN ACCREDITED PROGRAM OR RE-ACCREDITATION OF A PROGRAM: If the programinformation form is being completed for a currently accredited program, use the Continued Accreditation PIF inconjunction with the Web Accreditation Data System (Web ADS). Follow the provided instructions to create thecorrect 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 residentdata, retrieve Part 1 of the PIF under the Site Visit Information section, complete the shaded items (asappropriate), print all sections of Part 1 of the PIF and sign the form. If you find items displayed incorrectlychange your data using ADS update sections; in some instances you may need to contact your DIO for the entryof updated information. Next proceed to the section under the RRC for Neurological Surgery to retrieve Part 2 ofthe PIF for continued accreditation in either Word or WordPerfect. Complete Part 2 of the PIF using yourpreferred word processor (only after Part 1 has been completed). Combine Part 1 and Part 2, number the pagesconsecutively on the upper right corner, beginning with Part 1 Section 1 and complete the Table of Contents(found with the Part 2 instructions). Mail one set of the forms to the site visitor at least 10 working days before thesite visit. An additional copy should be held to permit corrections that may be required as the site visit proceeds.After the visit, three copies must be mailed to the Executive Director at the above address.Send 3 complete copies to the Executive Director of the RRC at the address given above. Supply informationwhich will indicate when you expect the program to be activated. The data and description given must be realisticand evidence should be included that your expectations are reasonable.The Program Director is responsible for the composition and accuracy of the information supplied in this form andmust sign it. It must also be signed by the Department Chairman/Chief of Service and the Designated InstitutionalOfficial of the sponsoring institution. Incomplete forms will not be accepted for review.The Institutional Requirements, the Program Requirements and the PIF may be downloaded from the ACGMEWebsite (www.acgme.org). For questions regarding the site visit, contact the writer of the letter announcing the site visit. For questions regarding the completion of the form (content), contact the Accreditation Administrator (Phone: 312-755-5028). For word processing questions/problems, contact the ACGME Help Desk (Phone: 312-755-7464). For technical questions about Part 1 of the PIF, email webads@acgme.org. For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.aspSPECIFIC INSTRUCTIONSInstructions have been provided at the top of each form. Please read them carefully before providing information.Please note that only these forms are to be used for supplying information and surgical statistics and onlyrequested information is to be attached. The information being submitted should be as concise as possible. Donot attach any unnecessary materials such as curriculum vitae, reprints, brochures, annual reports, minutes ofmeetings, etc. The RRC will not review unsolicited preprinted materials.This form is designed so that all information regarding intramural or multi-institution programs can be included onone set of forms. A complete set of these forms should be sent to each participating hospital so it can provide itsown statistics. The same reporting period must be used by all participating institutions. Information is to beresidency-review-committee-for-neurological-surgery2690.doc

collected by the Program Director for consolidation and transfer to a single set of forms. The Program Director isresponsible for overseeing the accurate compilation of requested data for all participating institutions.PART 1, SECTION 4: List the key neurological surgery staff under whose supervision the work of the residentstaff is performed. Occasional contributors to the program should not be included. List names in alphabeticalorder with their institution. Programs seeking continued accreditation must use the Accreditation Data System(ADS) to enter these data. The entered information will automatically appear in Part 1, Section 4 of the PIF.REQUEST FOR PROGRAM CHANGES: If the program is requesting approval to increase or decrease theresident complement, add or change participating institution, indicate this in Part 1 of the PIF and provide thesupport material. If the program is requesting an increase or decrease in the duration of training, please describethe change including the educational rationale and impact on training in a separate cover letter. Be sure todiscuss the requested change fully with the site visitor.AFFILIATION AGREEMENT(S): If the Program Information Forms comprise an application or reapplication for anew program, copies of current, signed affiliation agreements with each participating institution must accompanythese forms. For the resurvey of an existing program, current, signed affiliation agreements must be available forinspection by the site visitor. If the program is seeking approval to include a new participating institution within theprogram, a current, signed affiliation agreement must accompany these forms. All affiliation agreements mustconform to the Institutional Requirements (Attachment 1).SURGICAL LIST FOR INSTITUTIONS: Statistics are to be provided for the most recent full academic year (July1st to June 30th) for which this information is available. The same reporting period must be used by allparticipating institutions. The information is to be provided in separate totals for the Institutions staff and theresident(s) training at the institution. Grand totals are to be provided in the fifth column for all institutions. Formsmust be typed. All copies must be legible. NOTE: Computer print-outs or any other method employed inreporting INSTITUTIONAL statistics to the Residency Review Committee will not be accepted. Only the surgicallist provided is to be used. Use the "Other" category only for procedures that cannot be classified any other way.RESIDENTS SURGICAL LOG: The Residents Surgical Log is included with these forms. Statistics are to beprovided on this form only. Graduating Chief/Senior resident(s) must submit his/her ENTIRE neurological surgeryoperative experience gained within the approved institutions of the program. Foreign and/or external electiveexperiences should not be included. Combined surgical statistics from ALL institutions in which the residentserved during this time are to be compiled on this one form and not broken down into separate institutions.Please read carefully the instructions provided with the Residents Surgical Log. Make sure that dates andsignatures are provided. Logs will not be accepted without the proper signatures. Forms must be typed.EXAMPLES: For some sections of the Program Information Forms, an example page has been provided asguidance for completing the form. (The example is not intended to indicate the right way to do any particularprogram component but merely to provide a sample of a correctly completed form). Do not insert your programinformation on the example pages and do not include the example pages with your final submitted copies of theProgram Information Forms.SUBMITTING THE FORMS: 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 ofbinding. These will be removed and discarded.residency-review-committee-for-neurological-surgery2690.doc

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5027 • www.acgme.org PROGRAM INFORMATION FORMTABLE OF CONTENTSWhen you have the completed forms, number each page sequentially in the upper right hand corner. Starton Part 1, Section 1 of the PIF. Report this pagination in the Table of Contents and submit this cover page withthe completed PIF. 1Part 1 Section Page(s)General Program Information 1 Accreditation Information 1.A Program Director Information 1.BParticipating Institutions 2Resident Complement 3 Number of Positions 3.AFaculty / Teaching Staff 4 Faculty Roster 4.A Key Faculty Curriculum Vitae 4.B Part 2 Section Page(s)Background Information 5 Previous Citations or Concerns (if applicable) 5.A Changes (if applicable) 5.B Sponsoring Institution/Single or Limited Residency Institution (if applicable) 5.C General Competencies (if applicable) 5.DProgram Requests 6 Change in Residents 6.A Add/Delete Institution 6.BProgram Organizational Structure 1 7Statistical Information For Neurological Surgery and Neurology 81Residents Appointment 91Fellows 101Block Rotational Diagram 111Outpatient Department Information, Facilities and Chiefs 121Other Training Programs 131Educational Program Description 14 Narrative Description of the Program 14.A Training in Neurosciences [PR I.B.4] 14.B Experience in Stereotactic Radiosurgery (Mark one or more as appropriate) 14.C Experience in Endovascular Neurosurgery 14.D Conferences [PR V.B] 14.E Resident Research 14.F Program Directors Clinical Responsibility 14.G Moonlighting and Other Extracurricular Activities 14.H Supervision 14.I Duty Hours 14.Jresidency-review-committee-for-neurological-surgery2690.doc

Support Services 14.K Evaluation of Residents 14.L Evaluation of Faculty 14.M Evaluation of the Program 14.N Fellowships 14.O1Operative Experience 15 Residents 15.A Fellows 15.B Institutional 15.CAttachment 1: Affiliation Agreements for New Participating InstitutionsAttachment 2: Single Site SponsorAttachment 3: Call Scheduleresidency-review-committee-for-neurological-surgery2690.doc

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY 515 N State, Ste 2000, Chicago, IL 60610 • (312) 755-5027 • www.acgme.org PROGRAM INFORMATION FORM (Part 2) FOR CONTINUED ACCREDITATIONSECTION 5. BACKGROUND INFORMATIONA. Previous Citations or Concerns (if applicable) List the citations from the last RRC accreditation action and discuss how each cited area has been corrected. If documentation is required, provide a specific reference to information provided in the Program Information Forms such as the PSOL, etc., or append additional information supporting the narrative. If no citations were listed, indicate this in your response.B. Changes (if applicable) Briefly describe major changes, other than those included in the response to previous citations and/or concerns (above) that have been implemented since the last survey and review. Include changes in sponsoring organization, participating hospitals, required rotations, resident complement, faculty or facilities.C. Sponsoring Institution/Single or Limited Residency Institution (see ACGME Institutional Requirements) For those institutions which are either a single-program institution (e.g., neurological surgery only), or an institution with multiple residencies accredited by the same Residency Review Committee, 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: 1. 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 (Attachment 2). 2. Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how residents and faculty in the program are involved in the evaluation process. 3. 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 residents in accordance with the Program and Institutional Requirements. 4. Summarize how the institution complies with the ACGME Institutional Requirements regarding resident support, benefits and conditions of employment to include the details of the resident contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the resident contract/agreement to the PIF but state when it is given to the residents 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.)residency-review-committee-for-neurological-surgery2690.doc

5. Describe in detail the grievance (due process) procedure(s) that is available to residents, 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 resident’s contract, or other actions that could significantly threaten a resident’s intended career development.D. General Competencies (not applicable for new applications) 1The ACGME is monitoring the implementation of general competencies and assessment by using a common data collection tool. Log onto the Web Accreditation Data System and proceed to the Site Visit Information section and select Update/Verify Competency and Assessment Form to enter your information. Once the information has been entered and saved, select Print ADS Competency and Assessment Form to generate a printed copy of the form and attach it to the end of PIF.residency-review-committee-for-neurological-surgery2690.doc

SECTION 6. PROGRAM REQUESTS (not applicable for new applications)A. Change in Residents If any increase in the number of resident positions is being requested in Part 1, Section 3.A, provide the requested details below as to how this change affects the program and how the program complies with PR II.C.3.a-g. Requests for an increase should demonstrate institutional approval and financial support for the additional positions.B. Add/Delete Institution If any changes in the programs approved (i.e., institutions previously reviewed by the RRC) participating institutions are being requested in Part 1, Section 2, specify below the name of the institution, the number of months of training to be provided at this institution, and whether the institution is affiliated or integrated. Institution Name and # An Institution was: ( ) added/ changed to major site ( ) removed completely ( ) changed from major site to other (minor) site Type: ( ) Affiliated ( ) Integrated Number of Months (assigned by year): Impact on Program (short narrative):residency-review-committee-for-neurological-surgery2690.doc

SECTION 7. PROGRAM ORGANIZATIONAL STRUCTURE1. Is neurological surgery a separate unit (department/division/section) of surgery? ( ) YES ( ) NO2. If this is a medical school affiliated program, is neurological surgery a separate division or department within the medical school?3. How is the Chief of Neurological Surgery and/or Program Director appointed? Provide the information for each institution listed in Part 1, Section 2. Add more lines if needed. Institution #1: Chief: Program Director: Institution #2: Chief: Program Director: Institution #3: Chief: Program Director: Institution #4: Chief: Program Director:residency-review-committee-for-neurological-surgery2690.doc

SECTION 8. 1STATISTICAL INFORMATION FOR NEUROLOGICAL SURGERY AND NEUROLOGYProvide the information for each institution listed in Part 1, Section 2. Duplicate the tables to add more institutionsif needed.NEUROSURGICAL DATA Institution #1 Institution #2 Institution #3 Institution #4 TotalCurrent Hospital Bed CapacityNumber of Hospital Admissions/YearNeurosurgical Bed CapacityNumber of Neurosurgery Admissions/YearNeurosurgical Discharges/YearAverage Neurosurgery Census/DailyNumber of Neurosurgical Deaths/YearAverage Inpatient Consultations/DayAverage Neurosurgery ED Consultations/DayNEUROLOGY DATA Institution #1 Institution #2 Institution #3 Institution #4 TotalNumber of Neurology Admissions/YearAverage Neurology Census/Dailyresidency-review-committee-for-neurological-surgery2690.doc

SECTION 9. 1APPOINTMENT OF RESIDENTS1. Does the program routinely participate in the Neurosurgery Match? ( ) YES ( ) NO2. Date service begins for positions already offered:3. Date when appointments are made:4. How many years are appointments made for?5. Does the program appoint beginning residents at times other than the start of the academic year? ( ) YES ( ) NOresidency-review-committee-for-neurological-surgery2690.doc

SECTION 10. 1FELLOWSList all fellows currently appointed to this program (active clinical residents are listed in 3.B) and provide the information requested. For "Year of NS", givethe residents level of training. For "Description of Training Prior to NS appointment" give the name of the program and type of service. Example:Duke/NS. [PR V.D.6] Service Service Description of Training Prior to NSName Year of NS Medical School and Date of Graduation Begin End Appointmentresidency-review-committee-for-neurological-surgery2690.doc

SECTION 11. 1BLOCK ROTATIONAL DIAGRAMThis block rotational diagram should show the progression of a typical resident (or residents) through his/her educational experience. The PR forNeurological Surgery require that this educational experience be 60 months in length; the diagram should show how the sixty months of required trainingare spent. Using the six-month blocks, indicate where each resident will be for that period of time. Where rotations are less than six months the tablesections may be subdivided with the length of time indicated.The example provided reflects rotations for two residents, (X and Y) in a five-year program. During the NS1 year, both residents are on clinical rotations atHospital I. During the NS2 year, Resident X spends his/her first six months in pediatric neurosurgery at the Childrens Hospital, followed by three monthsof Neurology and three months of Neuropathology; the schedule for Resident Y is apparent. During the NS3 year, Resident X spends six months atHospital II (clinical service) and six months at Hospital I (clinical service); the rotation for Resident Y is apparent. For the NS4 year, Resident X spends sixmonths at Hospital II (clinical service) and six months in the laboratory. This resident subsequently spends twelve months in the laboratory during the NS5year and a year as Chief Resident during the NS6 year. [Add a "C" on the appropriate blocks to indicate when a resident is chief.]Block Rotational Diagram SampleYear July to December January to JunePGY-2 X: Hospital I Hospital I(NS1) Y: Hospital I Hospital IPGY-3 X: ELECTIVE Neurological/ ELECTIVE(NS2) Y: Neurological/ ELECTIVE ELECTIVEPGY-4 X: Hospital II Hospital I(NS3) Y: Hospital I Hospital IIPGY-5 X: Lab/ ELECTIVE Lab/ ELECTIVE(NS4) Y: Lab/ ELECTIVE Lab/ ELECTIVEPGY-6 X: Hospital I (C) Hospital II (C)(NS5) Y: Hospital II (C) Hospital I (C)PGY-7 Either 6th year of training and/or fellowshipFor 6 year programsBlock Rotational DiagramYear July to December January to JunePGY-2(NS1)PGY-3(NS2)PGY-4(NS3)PGY-5(NS4)PGY-6(NS5)PGY-7For 6 year programsresidency-review-committee-for-neurological-surgery2690.doc

SECTION 12. 1OUTPATIENT DEPARTMENT INFORMATION, FACILITIES AND CHIEFSProvide the information for each institution listed in Part 1, Section 2. Add another table for more institutions ifneeded. Provide the information requested for each hospital participating in the program. If position does notexist, enter "None." If position is vacant, enter "vacant." Institution #1 Institution #2 Institution #3 Institution #4Total Outpatient VisitsPercent Participation by Residents % % % %Emergency DepartmentTotal Number of NS Consultations/YearNeurologyFacilities [PR IV.A]Interventional Neuroradiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOStereotactic RadiosurgeryName of Following ChiefsChief of SurgeryChief of NeurologyNeuropathologistNeuroradiologistresidency-review-committee-for-neurological-surgery2690.doc

SECTION 13. 1OTHER TRAINING PROGRAMSAnswer "YES/NO" for the information requested below for each hospital participating in the program. [PR V.D.5]Other Training Programs In: Institution #1 Institution #2 Institution #3 Institution #4Anesthesiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOEndocrinology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOGeneral Surgery ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOInternal Medicine ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NONeurology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NONeuroradiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOphthalmology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOrthopaedics ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOOtolaryngology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPediatrics ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPathology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOPsychiatry ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NORadiology ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NO ( ) YES ( ) NOIf residencies do not exist for anesthesiology, endocrinology, ophthalmology, orthopaedics, otolaryngology,pathology, and psychiatry, describe the resources for education of neurological surgery residents below.residency-review-committee-for-neurological-surgery2690.doc

SECTION 14. 1EDUCATIONAL PROGRAM NARRATIVE DESCRIPTIONProvide a narrative in the following format, addressing each item. Repeat each section heading preceding yournarrative for each item. For each item, brevity is appreciated, but explain the program in significant detail. DONOT append brochures, program descriptions, curricula vitae, or other printed materials.A. Narrative Description of the Program 1. Describe the training program covering each year specifically. This information must include: a. A chronological rotation of assignments of residents; specify the total number of months of required clinical Neurological surgery. b. The duties of the residents in each year. c. Scheduled teaching rounds. d. Outpatient and inpatient facilities. e. Research facilities. f. Operating rooms and scheduled surgery days. Indicate whether the residents work simultaneously, or if not, How many work at one time and at what level in each institution listed. g. If the program trains more than one resident per year, describe how the program ensures that each resident has a full 12-month chief resident experience. h. Describe how the program provides progressively responsible patient management opportunities at each level of training. Include a description of the chief residents clinical and administrative responsibilities. i. Describe the outpatient experience and responsibilities of the residents, including the role of the resident in preoperative evaluation and management of patients as well as post-discharge follow up. j. Describe the critical care experiences of the residents. Indicate the specialty and position of the clinical director of the ICU. Describe the position of the individual responsible for the management of critical care neurosurgical patients. Describe the responsibility for management of critical care neurosurgical patients. k. List by name where each resident in the program took his/her neurology experience and in which years of training. 2. Describe whether the department is used for undergraduate teaching and if yes, by what medical school. Describe the role of the neurosurgery residents in teaching medical students and other residents. Indicate how many medical students are on the same team with the neurosurgery residents.B. Training in Neurosciences Describe the amount and type of training the residents receive in the following areas. Include a description of how this training is integrated into the clinical neurological surgery experience. Neurology Neuropathology Neuroanatomy Neurophysiology Neuroradiologyresidency-review-committee-for-neurological-surgery2690.doc

C. Experience in Stereotactic Radiosurgery (Mark one or more as appropriate) 1. What type of Radiosurgery is offered? ( ) None ( ) Leksell Gamma Unit ( ) Linear Accelerator ( ) Protein Beam or Particle Beam 2. Do residents have a defined experience in Stereotactic Radiosurgery? ( ) YES - required ( ) YES - elective ( ) NOD. Experience in Endovascular Neurosurgery Do residents have a defined experience in Endovascular Neurosurgery? ( ) YES ( ) NOE. Conferences Provide a schedule of departmental conferences for the most recent academic year held with resident staff and list other formal teaching exercises including Journal Club. The schedule should include the frequency and year the topic, and the name of the individual responsible for oversight of the conference, and the name of the individual presenting the conference. Below Indicate the "Type" and "Frequency" of conferences and who is required to attend (resident and/or faculty). Type Frequency Residents Required to Attend Faculty Required to Attend Neurosurgical Neuropathology Tumor Clinics M and M Neurological Neuroradiological OtherF. Resident Research List the papers published since the last survey of the program in which a resident of the program was author or joint author. Underline the resident participants name.G. Program Directors Clinical Responsibility Describe the program directors major clinical responsibilities at the primary clinical site as well as any responsibilities he/she may have at other participating institutions.H. Moonlighting and Other Extracurricular Activities Describe the programs policy on moonlighting.I. Supervision Describe how the program ensures direct and appropriate supervision of residents at each level of training.J. Duty Hoursresidency-review-committee-for-neurological-surgery2690.doc

Attach the call schedule (Attachment 3).K. Support Services Describe the support services the program/institution provides to ensure that residents do not routinely engage in activities that do not require the skills of a physician. Describe the type and availability of sleeping, lounge, and food facilities provided to residents on-call in the hospital.L. Evaluation of Residents Describe how the program systematically evaluates each resident, communicates such evaluation to the residents, and documents both the evaluation and the communication.M. Evaluation of Faculty Describe how the program evaluates faculty. How is resident evaluation kept confidential?N. Evaluation of the Program Describe how the residents and faculty evaluate the conferences and rotations of the residency.O. Fellowships Attach a description of any fellowship(s) the program offers, and include an operative log for each most recently graduated fellow. Describe how the Program Director ensures that the fellow does not adversely affect the experience of the residents. Include the number of fellows currently in the programs.residency-review-committee-for-neurological-surgery2690.doc

SECTION 15. 1OPERATIVE EXPERIENCEA. 1Residents1Supply the number of cases for the most recently graduating resident representing his/her entire neurosurgery experience. This information is to bereported separately: by senior clinical year, and by all other clinical years. Combined surgical statistics from ALL institutions in which the resident servedare to be included on this one form and not broken down into separate institutions. Count only those cases in which the resident had a significant decisionmaking role (including pre- and post-operative care). "Surgeon" refers to primary responsibility; "Assistant" refers to surgeon acting as an assistant.Patients up to 16 years of age inclusive are considered pediatric cases. Procedures listed as "Other", should be explained in the "Other" section of thislog. Attach additional pages as necessary.Residents NameLog Covering Period (dates)Resident SignatureADULT Senior Clinical Year Other Clinical Years Total Experience All YearsTumor Glial tumor or metastasis - craniotomy Glial tumor or metastasis - stereotactic biopsy Glial tumor or metastasis - radiosurgery Meningioma - craniotomy Meningioma - radiosurgery CP angle tumor - craniotomy CP angle tumor - radiosurgery Sellar/Parasellar tumor - craniotomy Sellar/Parasellar tumor - transsphenoidal Sellar/Parasellar tumor - radiotherapy Other (tumor)Total TumorVascular Aneurysm - craniotomy Aneurysm - endovascular AVM - craniotomy AVM - endovascular AVM - radiosurgeryresidency-review-committee-for-neurological-surgery2690.doc

ADULT Senior Clinical Year Other Clinical Years Total Experience All Years Occlusive disease - carotid endarterectomy Occlusive disease - endovascular Occlusive disease - EC/IC bypass Non-traumatic intracerebral hematoma Other (vascular)Total VascularHead Trauma Depressed skull fracture Gunshot/penetrating wound Epidural hematoma Subdural hematoma Intracerebral hematoma Other (head trauma)Total Head TraumaFunctional Epilepsy - diagnostic Epilepsy therapeutic - craniotomy Epilepsy therapeutic - vagal nerve stimulation Movement disorder surgery - stereotactic lesion creation Movement disorder surgery - implantation of stimulator Neuralgia - percutaneous lesion creation Neuralgia - craniectomy for decompression Neuralgia - stereotactic radiosurgery Other (functional)Total FunctionalSpine Disc/Spondylosis cervical - discectomy/decompression without instrumentation Disc/Spondylosis cervical - with instrumentation Disc/Spondylosis thoracic - discectomy/decompression without instrumentation Disc/Spondylosis thoracic - with instrumentationresidency-review-committee-for-neurological-surgery2690.doc

ADULT Senior Clinical Year Other Clinical Years Total Experience All Years Disc/Spondylosis lumbar - discectomy/decompression without instrumentation Disc/Spondylosis lumbar - with instrumentation Primary tumor - resection without instrumentation Primary tumor - resection with instrumentation Metastatic tumor - resection without instrumentation Metastatic tumor - resection with instrumentation Trauma - operative decompression/reduction without instrumentation Trauma with instrumentation Other (spine)Total SpinePeripheral Nerve Neuroplasty (entrapment release, neurolysis, transposition) Neurorrhaphy Other (peripheral nerve)Total Peripheral NerveCSF Shunting Initial Revision Third ventriculostomyTotal CSF ShuntingMiscellaneous MiscellaneousTotal ADULT Cases:residency-review-committee-for-neurological-surgery2690.doc

PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsHead Trauma (pediatric)Brain Tumor (pediatric)Cranial Synostosis/Craniofacial Reconstruc (PED)Functional (pediatric)EpilepsyPump implantationRhizotomyTotal Functional (pediatric)Spinal Dysraphism (pediatric)CSF Shunting (pediatric)InitialRevisionThird ventriculostomyTotal CSF Shunting (pediatric)Other (pediatric)ADULT & PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsMinor Procedures (Adult & Pediatric)Muscle/nerve biopsy, ICP monitor, tongs/halo, etc.Total ADULT & PEDIATRIC Cases:Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All Years1. Angiogram2. Myelogram3. Ventriculogram4. Otherresidency-review-committee-for-neurological-surgery2690.doc

Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All YearsGrand Total: Diagnostic ProceduresSpecify "Other" Procedures: Please check whether the "other" procedure is recorded under MAJOR, MINOR or DIAGNOSTIC (DIAG); ADULT orPEDIATRICS (PEDS). The "CAT" column refers to the number of the category in which the "other" procedure is recorded. For example, if the "other"procedure is recorded under the category, "Craniotomy Other than Trauma," then in the "CAT" column the number one (1) should be listed. Duplicate thispage as needed. 1 Senior Clinical Year Other Clinical YearsMajor Minor Diag. Adult Peds Cat Description Of Procedure Surgeon Assistant Surgeonresidency-review-committee-for-neurological-surgery2690.doc

B. Fellows1Supply the number of cases for the most recently graduated fellow representing his/her entire neurosurgery fellowship experience. This information is tobe reported separately: by Surgeon, Assistant, and by Teaching Assistant. Combined surgical statistics from ALL institutions in which the fellow servedare to be included on this one form and not broken down into separate institutions. Count only those cases in which the fellow had a significant decisionmaking role (including pre- and post-operative care). "Surgeon" refers to primary responsibility; "Assistant" refers to surgeon acting as an assistant;"Teaching Assistant" refers to supervisory responsibility. Patients up to 16 years of age inclusive are considered pediatric cases. Procedures listed as"Other", should be explained in the "Other" section of this log. Attach additional pages as necessary.Fellows NameLog Covering Period (dates)ADULT Senior Clinical Year Other Clinical Years Total Experience All YearsTumor Glial tumor or metastasis - craniotomy Glial tumor or metastasis - stereotactic biopsy Glial tumor or metastasis - radiosurgery Meningioma - craniotomy Meningioma - radiosurgery CP angle tumor - craniotomy CP angle tumor - radiosurgery Sellar/Parasellar tumor - craniotomy Sellar/Parasellar tumor - transsphenoidal Sellar/Parasellar tumor - radiotherapy Other (tumor)Total TumorVascular Aneurysm - craniotomy Aneurysm - endovascular AVM - craniotomy AVM - endovascular AVM - radiosurgery Occlusive disease - carotid endarterectomy Occlusive disease - endovascular Occlusive disease - EC/IC bypass Non-traumatic intracerebral hematomaresidency-review-committee-for-neurological-surgery2690.doc

ADULT Senior Clinical Year Other Clinical Years Total Experience All Years Other (vascular)Total VascularHead Trauma Depressed skull fracture Gunshot/penetrating wound Epidural hematoma Subdural hematoma Intracerebral hematoma Other (head trauma)Total Head TraumaFunctional Epilepsy - diagnostic Epilepsy therapeutic - craniotomy Epilepsy therapeutic - vagal nerve stimulation Movement disorder surgery - stereotactic lesion creation Movement disorder surgery - implantation of stimulator Neuralgia - percutaneous lesion creation Neuralgia - craniectomy for decompression Neuralgia - stereotactic radiosurgery Other (functional)Total FunctionalSpine Disc/Spondylosis cervical - discectomy/decompression without instrumentation Disc/Spondylosis cervical - with instrumentation Disc/Spondylosis thoracic - discectomy/decompression without instrumentation Disc/Spondylosis thoracic - with instrumentation Disc/Spondylosis lumbar - discectomy/decompression without instrumentation Disc/Spondylosis lumbar - with instrumentation Primary tumor - resection without instrumentationresidency-review-committee-for-neurological-surgery2690.doc

ADULT Senior Clinical Year Other Clinical Years Total Experience All Years Primary tumor - resection with instrumentation Metastatic tumor - resection without instrumentation Metastatic tumor - resection with instrumentation Trauma - operative decompression/reduction without instrumentation Trauma with instrumentation Other (spine)Total SpinePeripheral Nerve Neuroplasty (entrapment release, neurolysis, transposition) Neurorrhaphy Other (peripheral nerve)Total Peripheral NerveCSF Shunting Initial Revision Third ventriculostomyTotal CSF ShuntingMiscellaneous MiscellaneousTotal ADULT Cases:residency-review-committee-for-neurological-surgery2690.doc

PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsHead Trauma (pediatric)Brain Tumor (pediatric)Cranial Synostosis/Craniofacial Reconstruc (PED)Functional (pediatric)EpilepsyPump implantationRhizotomyTotal Functional (pediatric)Spinal Dysraphism (pediatric)CSF Shunting (pediatric)InitialRevisionThird ventriculostomyTotal CSF Shunting (pediatric)Other (pediatric)ADULT & PEDIATRIC Senior Clinical Year Other Clinical Years Total Experience All YearsMinor Procedures (Adult & Pediatric)Muscle/nerve biopsy, ICP monitor, tongs/halo, etc.Total ADULT & PEDIATRIC Cases:Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All Years1. Angiogram2. Myelogram3. Ventriculogram4. Otherresidency-review-committee-for-neurological-surgery2690.doc

Diagnostic Procedures -Adult and Pediatric Senior Clinical Year Other Clinical Years Total Experience All YearsGrand Total: Diagnostic ProceduresSpecify "Other" Procedures: Please check whether the "other" procedure is recorded under MAJOR, MINOR or DIAGNOSTIC (DIAG); ADULT orPEDIATRICS (PEDS). The "CAT" column refers to the number of the category in which the "other" procedure is recorded. For example, if the "other"procedure is recorded under the category, "Craniotomy Other than Trauma," then in the "CAT" column the number one (1) should be listed. Duplicate thispage as needed. 1 Senior Clinical Year Other Clinical YearsMajor Minor Diag. Adult Peds Cat Description Of Procedure Surgeon Assistant Surgeonresidency-review-committee-for-neurological-surgery2690.doc

C. 1Institutional Operative ExperienceSupply the number of cases for each institution participating in the program. Attach a description of how the data were tabulated and the method used toconfirm the accuracy of the information reported. Operative experience for the previous academic year should be reported.Log Covering Period (dates) July 1, ---- to June 30, ----Program Director Signature / DateADULT Institution 1 Institution 2 Institution 3 Institution 4 Total ExperienceTumor Glial tumor or metastasis – craniotomy Glial tumor or metastasis – stereotactic biopsy Glial tumor or metastasis - radiosurgery Meningioma – craniotomy Meningioma – radiosurgery CP angle tumor – craniotomy CP angle tumor – radiosurgery Sellar/Parasellar tumor – craniotomy Sellar/Parasellar tumor - transsphenoidal Sellar/Parasellar tumor – radiotherapy Other (tumor)Total TumorVascular Aneurysm – craniotomy Aneurysm – endovascular AVM – craniotomy AVM – endovascular AVM – radiosurgery Occlusive disease - carotid endarterectomy Occlusive disease – endovascular Occlusive disease - EC/IC bypass Non-traumatic intracerebral hematoma Other (vascular)Total Vascularresidency-review-committee-for-neurological-surgery2690.doc

ADULT Institution 1 Institution 2 Institution 3 Institution 4 Total ExperienceHead Trauma Depressed skull fracture Gunshot/penetrating wound Epidural hematoma Subdural hematoma Intracerebral hematoma Other (head trauma)Total Head TraumaFunctional Epilepsy - diagnostic Epilepsy therapeutic - craniotomy Epilepsy therapeutic - vagal nerve stimulation Movement disorder surgery - stereotactic lesion creation Movement disorder surgery - implantation of stimulator Neuralgia - percutaneous lesion creation Neuralgia - craniectomy for decompression Neuralgia - stereotactic radiosurgery Other (functional)Total FunctionalSpine Disc/Spondylosis cervical - discectomy/decompression without instrumentation Disc/Spondylosis cervical - with instrumentation Disc/Spondylosis thoracic - discectomy/decompression without instrumentation Disc/Spondylosis thoracic - with instrumentation Disc/Spondylosis lumbar - discectomy/decompression without instrumentation Disc/Spondylosis lumbar - with instrumentation Primary tumor - resection without instrumentation Primary tumor - resection with instrumentationresidency-review-committee-for-neurological-surgery2690.doc

ADULT Institution 1 Institution 2 Institution 3 Institution 4 Total Experience Metastatic tumor - resection without instrumentation Metastatic tumor - resection with instrumentation Trauma - operative decompression/reduction without instrumentation Trauma with instrumentation Other (spine)Total SpinePeripheral Nerve Neuroplasty (entrapment release, neurolysis, transposition) Neurorrhaphy Other (peripheral nerve)Total Peripheral NerveCSF Shunting Initial Revision Third ventriculostomyTotal CSF ShuntingMiscellaneous MiscellaneousTotal ADULT Cases:PEDIATRIC Institution 1 Institution 2 Institution 3 Institution 4 Total ExperienceHead Trauma (pediatric)Brain Tumor (pediatric)Cranial Synostosis/Craniofacial Reconstruc (PED)Functional (pediatric)EpilepsyPump implantationresidency-review-committee-for-neurological-surgery2690.doc

PEDIATRIC Institution 1 Institution 2 Institution 3 Institution 4 Total ExperienceRhizotomyTotal Functional (pediatric)Spinal Dysraphism (pediatric)CSF Shunting (pediatric)InitialRevisionThird ventriculostomyTotal CSF Shunting (pediatric)Other (pediatric)ADULT & PEDIATRIC Institution 1 Institution 2 Institution 3 Institution 4 Total ExperienceMinor Procedures (Adult & Pediatric)Muscle/nerve biopsy, ICP monitor, tongs/halo, etc.Total ADULT & PEDIATRIC Cases:Diagnostic Procedures -Adult and Pediatric Institution 1 Institution 2 Institution 3 Institution 4 Total Experience1. Angiogram2. Myelogram3. Ventriculogram4. OtherGrand Total: Diagnostic Proceduresresidency-review-committee-for-neurological-surgery2690.doc

RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY

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RESIDENCY REVIEW COMMITTEE FOR NEUROLOGICAL SURGERY Document Transcript