Complement Change Request Form

Statement of Purpose

The Neurohospitalist Society fellowship accreditation committee reviews and accredits neurohospitalist fellowship programs to ensure a standard level of educational quality and to promote training opportunities for neurohospitalists.

Complement Change Request Form

Use this form to request an increase in the total number of fellows your program is accredited to train annually. The fee for a complement change request when submitted separately from the annual status report or biennial program evaluation report is $500.

We recommend utilizing the "save" button at the bottom of the page as you fill out the form, if needed. A link will be emailed to you.

For more information, please contact the Accreditation Committee at accreditation@neurohospitalistsociety.org.

Primary Contact Name

First Name Last Name Degree(s)

Email

example@example.com

Institution

Are you filling out this form for the sole purpose of requesting an increase in the number of fellows you train annually?

Yes No

You have selected the wrong form. Please return to the main accreditation page and start again.

Specify the number of fellows trained per year previously. If the number varies from year to year, enter a range, e.g., “0 to n”:

Specify the new number of fellows you wish to train per year. If the number varies from year to year, enter a range, e.g., “0 to n”:

Specify the source of funding for the expanded neurohospitalist fellowship position(s) (e.g., health system, department, etc.). If there are multiple sources of funding please list all of them.

Explain the educational rationale for training additional fellows. This must include a statement that the educational environment can accommodate additional learners without compromising experience of existing learners.

Provide a sample schedule that illustrates how the fellowship plans to accommodate multiple learners. A sample schedule is provided here. Note, in this example both learners are never on the same rotation at the same time, but that does not preclude this option if a rotation can provide a robust learning experience for two fellows simultaneously.

Upload the fellowship sample schedule illustrating multiple learner accommodation here (PDF format):

Upload letter, signed by the department chair, stating their support of the neurohospitalist fellowship program, stating their support of the fellowship director, and listing the resources provided to administer the program (including but not limited to %FTE support for Fellowship Director, %FTE support for Fellowship Coordinator, and source of funding for Fellowship position). Ensure that the letter specifically mentions support of the change in the number of fellows trained per year.

Please check the box below: *

By submitting this form, I attest that all the information submitted herein is true and correct.

Signature of fellowship director *

Clear

Date/time

Please choose your payment method. Payment must be received in order to process your application.

Check Invoice (emailed to primary contact) Credit card

Please make your check payable to the Neurohospitalist Society and mail to:

The Neurohospitalist Society
Attn: Amanda Pacia
1100 Melody Lane, Suite 2003
Roseville, CA 95678

*** Payment must be received by in order to process your application.

Payment

Complement Change Request Includes 3% credit card processing fee

$ 515.00

Total

$ 0.00

Credit Card
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Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email for receipt

example@example.com