GMEC Multi-Request Form (CAP, Exceptionally Qualified, NST, New PD/APD)

GME Multi-Requests Form

Complement and Additions to Programs (CAP), Exceptionally Qualified Candidate, Non-Standard Training (NST) Program, or New Program Director or New Associate Program Director

The deadline to submit applications is fourteen days prior the upcoming meeting.

CAP meets on the last Monday of each month, holiday permitting.
GMEC meets on the first Monday of each month, holiday permitting.
NST convenes quarterly.

CAP (last Monday)	NST (Quarterly)	GMEC (first Monday)
June	August/September	July
July	December/January	August
September	March/April	October
October	June	November
December		January
January		February
March		April
April		May

The fiscal year for each hospital varies and budgets are considered during periods defined in the table below.

Hospital	Fiscal Year
CUH	September-August
CMC	January-December
PHHS	October-September
TSRH	August-July
VA	July-June

CAP/NST/GMEC actions will be communicated via email from the GME Office. Approved requests may need to be submitted to an external accreditation/approval body (e.g., ACGME, TMB, etc.). It is the responsibility of the Programs to ensure such requests are submitted in accordance with established deadlines.

For ACGME accredited programs, please make sure to review the dates for your specialty's RRC scheduled meeting.

I have read and understand the information provided above.*

YesNo
Please reread or open the policy & procedure links!

Contact the GME Office if you are confused about this form or your responsibilities.

What type of request is this?*

Complement and Additions to Programs (CAP) RequestExceptionally Qualified Candidate RequestNon-Standard Training (NST) RequestNew Program Director or Associate Program Director Request

Exceptionally Qualified Applicant Request
Request for Exception for an Exceptionally Qualified Applicant whose required pre-fellowship training was not in an ACGME-accredited or RCPSC-accredited residency program.

Please review the Eligibility Exceptions for Exceptionally Qualified Applicants Procedure and the Passage of Medical Licensing Examination Policy prior to completing this form.

(Not available to fellowships in Neurology, OBGYN, Plastic Surgery, PM&R, Psychiatry, Radiation Oncology, Surgery, and Urology)
- The program director and fellowship selection committee have found the applicant suitable to enter the fellowship based upon a review of prior training and summative evaluations of training in the core specialty.*
  
  YesNo
- Program Name:*
- Program:
- If "Other", please list the full name of the program:
- Accreditation Number:*
- Program Director
- Program Director's Name:*
  
  First NameLast Name
- Program Director's Email:*
  example@example.com
- Program Coordinator
  
  Must be the titled GME Program Coordinator. Admins, Educational Coordinators, Managers, etc. will not be accepted.
- Program Coordinator's Name:*
  
  First NameLast Name
- Program Coordinator's Email:*
  example@example.com
- Applicant Name:*
  
  First NameLast Name
- Expected PGY Level:*
- Please upload the applicant's current CV:*
  
  Cancelof
- Please upload the applicants Step 1 USMLE/COMLEX Scores:*
  
  Cancelof
- Please upload the applicants Step 2 USMLE/COMLEX Scores:*
  
  Cancelof
- Please upload the applicants Step 3 USMLE/COMLEX Scores:*
  
  Cancelof
- Please upload the applicants ECFMG certificate:*
  
  Cancelof
- Please provide evidence that the applicant has demonstrated clinical excellence, in comparison to his/her peers, throughout training:*
- Please provide evidence for one or more of the following:*
  
  Participation in additional research training in the specialtyDemonstrated scholarship in the specialtyDemonstrated leadership during or after residency trainingCompletion of an ACGME-international accredited residency program
- Please provide evidence that the applicant has demonstrated additional research training in the specialty:*
- Please provide evidence that the applicant has demonstrated scholarship in the specialty:*
- Please provide evidence that the applicant demonstrated leadership during or after residency training:*
- Please provide evidence that the applicant completed an ACGME-accredited program:*
- Please provide a letter of support signed by both the Fellowship Program Director & the Core Program Director.*
  
  Cancelof
- Additional document information:
  
  Cancelof
- Additional comments/information:
- If the exception is granted, the program will complete a fellowship Milestones evaluation (for the purposes of establishment of baseline performance by the Clinical Competency Committee), within twelve weeks of matriculation.
  
  With approval of the UTSW GME Office, this evaluation may be waived for an applicant who has completed an ACGME International-accredited residency based on the applicant’s Milestones evaluation conducted by the residency program.
  
  If the trainee does not meet the expected level of Milestone competencies following entry into the fellowship program, the trainee will undergo a period of remediation, overseen by the Clinical Competency Committee and monitored by the GMEC. This period of remediation will not count toward time in fellowship training.
- If this request is complete and ready to submit to CAP for review, please hit submit.
  
  If a request is submitted with incomplete information, the request could be denied which can result in a delayed response from CAP.

CAP Request

Adding or Modifying a Program
Contact Information

Section 1 of 5
The CAP committee requires this form for actions including applying for a new program, modifying resident/fellow complement, seeking accreditation, withdrawing a program, updating participating sites, or program name changes. Please provide necessary details such as program name, justification, accreditation requirements, funding, supporting documents, and leadership approvals. Ensure all required fields are complete, attach supporting materials, and submit for the CAP committee for review.

Please be sure to reference the CAP Request Procedure prior or during completion of this form.
For this section:
- Include the name of the individual that prepared the CAP application
- Program Coordinator’s name and email
- Program Director’s name and email
- Core Program Director’s email, if applicable
- Department Chair email
- This application was prepared by:*
  
  First NameLast Name
- Program Director
- Program Director:*
  
  First NameLast Name
- Program Director's Email:*
  example@UTSouthwestern.edu
- Core Program Director's Email:
  The department's main residency PD
- Program Coordinator
  
  Must be the titled GME Program Coordinator. Admins, Educational Coordinators, Managers, etc. will not be accepted.
- Program Coordinator Name:*
  
  First NameLast Name
- Program Coordinator Email:*
  example@UTSouthwestern.edu
- Contact's Phone Number:*
  Office or UT Southwestern numbers only.
- Department Chair
- Department Chair Name:*
  
  First NameLast Name
- Department Chair Email:*
  Must be the department, not division chief's email.

Proposed Changes

Section 3 of 5
For this section:
- Specify the planned implementation date for the proposed actions, assuming all necessary approvals are secured.
- Include the current number of approved and filled positions, along with the number of new positions being requested, to ensure clarity in your request.
- If requesting multiple new positions with a phased approach to filling them, provide a detailed implementation plan outlining the timeline and process.
- Provide any necessary information to aid the CAP Committee in understanding what you are requesting and how it will benefit the residents and/or program.
- The brief educational rationale should be written in a manner that would be appropriate to submit to the accrediting or approving body (ACGME or TMB, etc.).
- Note that actions impacting other programs will require a separate CAP application.
- Effective date of the proposed change(s) or new program start date:*
  
  MonthDayYear
  Date
- Number of approved positions (currently):*
  This is the officially approved number by the accrediting body of this program.
- Number of positions filled (currently):*
  At the time of submission, how many trainees are in the program?
- Number of requested positions:
- Does your program have a key faculty requirement?*
  
  YesNo
- Note: Not all programs have this requirement. Some ACGME Program Requirements include specific faculty-to-resident/fellow ratios to ensure adequate supervision and educational quality. These ratios vary by specialty and by program type (residency vs. fellowship). Many residency programs aim for a 1:6 faculty-to-resident ratio, while certain fellowship programs may require a 1:1 faculty-to-fellow ratio.
- Required Key Faculty/Resident Ratio:*
  ex. 5:1 (5 Faculty to 1 Resident)
- Proposed Faculty/Resident Ratio:*
  ex. 5:1 (5 Faculty to 1 Resident)
- Current Faculty/Resident Ratio:*
  ex. 6:1 (6 Faculty to 1 Resident)
- Provide an explanation for the program name change:*
  (ex. NST name requirement or certifying board name change)
- Provide a detailed description of the proposed changes or new program:*
- Provide a brief description of the education rationale for the proposed changes or new program:*
- Provide a brief description of how the proposed changes or new program will affect other GME learners:*
- Major changes: *
- List major changes (i.e. sites of service, changes in faculty, change in program director or program coordinator, etc.) in the last academic year.

	FTE(s) for Program Funding
Department
CUH
PHHS
Children's
VA
Texas Scottish Rite
Grant (1)
Grant (2)
Other

	FTE(s) for Program Funding
Department
CUH
PHHS
Children's
VA
Texas Scottish Rite
Grant (1)
Grant (2)
Other

Required Documents

Section 5 of 5
Required Documents:
- For each CAP action you are requesting, please ensure that all documents indicated are included with your request.
- It is best practice to label your documents according to the list of required documents specified in the CAP Procedure, followed by the program name (i.e. Current Block Diagram_Pediatric Hepatology).
- Including the ACGME Letter of Notification (LON) or TMB approval notice (email) will ensure that the program has reviewed it and will aid the CAP Committee in reviewing requests.
*If a required document is unavailable for a legitimate reason, you may upload a Word document providing a detailed explanation of why the program does not have the requested document.
Other Specified Application:*

Used for: New ACGME, New TMB, Renew TMB, New Other
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Please use the ACGME Block Diagram Guide.

Note: Some ACGME accredited programs have specialty-specific Block Diagram templates. Please refer to the Documents and Resources page for your specialty to ensure you are using the correct template.

Block Diagram must be reviewed/approved by the GME Office.
Proposed Block Diagram:

Used for: New ACGME, New TMB, (if applicable) Renew TMB, Add Site, Delete Site, (if applicable) Modify Existing, Comp Increase Temp, Comp Increase Perm, Comp Decrease
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Current Block Diagram (from ADS):*

Used for: (if applicable) New ACGME, Renew TMB, Add Site, Delete Site, (if applicable) Modify Existing, Comp Increase Temp, Comp Increase Perm, Comp Decrease
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Competency-Based G&O:*

(Must be site specific and show delineation in responsibilities among program years) Used for: New ACGME, New TMB, Renew TMB, New Other, Add Site, (if applicable)
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PD Curriculum Vitae:*

Used for: New ACGME, New TMB, (if applicable) Renew TMB, New Other, (if applicable) Modifying Exisiting
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PD Chair Support Letter:*

Used for: New ACGME, New TMB, (if applicable) Renew TMB, New Other, (if applicable) Modifying Exisiting
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LON/TMB Approval Notice:*

Used for: Renew TMB, Add Site, Delete Site, Withdraw Program, Modify Existing, Comp Increase Temp, Comp Increase Perm, Comp Decrease
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Is this request for either the General Surgery, Pediatric Surgery, Vascular Surgery, Complex General Surgical Oncology, or Surgical Critical Care program?*

YesNo
The Review Committee for Surgery requires all programs complete the Institutional Operative Experience form when requesting permanent complement increases. Please download the form that corresponds to your specific program.

For more information on complement increases, visit the Documents and Resources tab in the Surgery section of the ACGME website.
Institutional Operative Experience Form:*

Use for: ACGME accredited Surgery Programs (General Surgery, Pediatric Surgery, Vascular Surgery, Complex General Surgical Oncology, & Surgical Critical Care) require that the Institutional Operative Experience form is submitted for all permanent compliment increase requests
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Program Letter of Agreement(s):*

Combine all PLAs into one document. Please note PLAs are required for all rotations outside of UTSW.
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Semi-Annual Evaluation:*

Combine all PLAs into one document. Please note PLAs are required for all rotations outside of UTSW.
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Summative Evaluation:*

Combine all PLAs into one document. Please note PLAs are required for all rotations outside of UTSW.
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Final Evaluation:*

Combine all PLAs into one document. Please note PLAs are required for all rotations outside of UTSW.
Cancelof
Additional Documents:

Used for: Any additional documents the program might want to include (not required)
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If this request is complete and ready to submit to CAP for review, please hit submit.

If a request is submitted with incomplete information, the request could be denied which can result in a delayed response from CAP.
All New Program submissions require a New PD Application Submission

When submitting a New Program application, you must also complete a New PD Application Submission simultaneously for consideration.

All New Program submissions require a New PD Application Submission

When submitting a New Program application, you must also complete a New PD Application Submission simultaneously for consideration.
Click "NEXT" to complete the New PD Form.

New Program Director or Associate Program Director
Minimum qualifications for the GME Program Director position include:
- Requisite expertise in the medical specialty
- Documented educational and administrative experience
- Current certification in the specialty by the appropriate American Board of Medical Specialties member board or equivalent specialty qualifications
- Current medical licensure
- Appropriate medical staff appointment
- Additional qualifications may be specified and required by accreditation/approval bodies and/or the GMEC
The Program Director must devote a portion of their professional effort to the oversight and management of the program:
- For ACGME programs, the program director must be provided with the dedicated time and support specified for administration of the program in accordance with the minimum support in the specialty program requirements
- For non-ACGME programs, the Program Director must be provided with support (which may include salary support) adequate for administration of the program based upon its size and configuration
Please review the GME Program Directors Policy prior to completing this form.
- The program acknowledges that the nominee meets the qualifications to serve as a Program Director in accordance with ACGME requirements and the GME Office’s Program Director policy. This determination is based on a thorough review of the nominee’s credentials and prior training, ensuring their suitability for this leadership role.*
  
  YesNo
- Is this for a new program?*
  
  YesNo
- Program Name:*
- Program:
  Select 'Other' if your program is not listed or if it is a new program
- If "Other", please list the full name of the program:
- Accreditation Number:*
- Program Coordinator
  
  Must be the titled GME Program Coordinator. Admins, Educational Coordinators, Managers, etc. will not be accepted.
- Program Coordinator's Name:*
  
  First NameLast Name
- Program Coordinator's Email:*
  example@example.com
- Is this request for a new _________?*
  
  Program Director (PD)Associate Program Director (APD)
- Name of Nominee:*
  
  First NameLast Name
- Nominee's Email:*
  example@UTSouthwestern.edu
- Appointment Date:*
- Dedicated FTE for APD role:*
- List of Job Duties Delegated by the Program Director:*
- Department Chair Nomination Letter:*
  
  Chair letter must include language that the PD will be provided the FTE required by ACGME
  Cancelof
- Nominee's Current CV:*
  
  Cancelof
- Additional comments/information:
- If this request is complete and ready to submit to GMEC for review, please hit submit.
  
  If a request is submitted with incomplete information, the request could be denied which can result in a delayed response from GMEC.

Non-Standard Training Program Request
Programs wishing to apply for NST status through ACGME must meet all the requirements and provide requested documents. ECFMG is relinquishing their role and programs who wish to recruit J-1 Visa holders must have NST status. Please review the ACGME’s Recognition Requirements for Sponsoring Institutions with Non-Standard Training Programs for J-1 Visa Sponsorship. Please also review the Non-Standard Training Program Policy.

Programs must provide documentation in accordance with the ACGME NST Program Requirements. All documents will be reviewed prior to approval and submission. Programs may not recruit applicants holding a visa prior to ACGME NST status is approval.
- The Program acknowledges that it has reviewed the UTSW NST Policy, the ACGME Recognition Requirements for Sponsoring Institutions with NST programs for J-1 Visa Sponsorship, and the ACGME-approved Focus Area list, and will comply with all applicable requirements before recruiting J-1 Visa holders.*
  
  YesNo
- Is this a new program to UT Southwestern?*
  
  YesNo
- CAP Application
  
  Please be aware, a new program to UT Southwestern requires a CAP application and GMEC approval. Please be sure you have submitted this and followed those procedures.
- Complement and Addition to Programs (CAP) Request Procedure & Application
- Have you submitted a CAP application that's been approved by both CAP and GMEC?*
  
  YesNo

Program Information

Section 2 of 2

Each NST program must have a single program director, selected from the physician faculty of the most closely related ACGME-accredited residency or fellowship program, who is responsible for its overall operation. Additionally, programs must maintain sufficient personnel to effectively support their administration and training objectives.
Program Director
Program Director's Name:*

First NameLast Name
Program Director's Email:*
Jane.Doe@UTSouthwestern.edu
Program Director's Phone Number:*
Office or UT Southwestern numbers only.
Specify any required qualifications of the NST program director:*
Please list the requirements for a program director to be eligible to hold the position, do not list the qualifications of the current program director.
Program Coordinator

Must be the titled GME Program Coordinator. Admins, Educational Coordinators, Managers, etc. will not be accepted.
Program Coordinator's Name:*

First NameLast Name
Program Coordinator's Email:*
Jane.Doe@UTSouthwestern.edu
Phone Number:*
Office or UT Southwestern numbers only.
NST Program Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary/Core Faculty
List all faculty members other than the NST program director who have responsibility for education or supervision of trainees in the NST program:*
First / Last / Degree / Participating Site (select); add entries as needed.

ACGME Examples of Non-Standard Training Programs is a list of names that have been recognized for J-1 Visa Sponsorship. It is preferred for your program name to be one from this list, but you may request an alternative name to be approved. This list will provide you with the most closely related ACGME program which you must reference when submitting documents. Trainee assignments/ rotations must be limited to the most closely related ACGME program sites identified by the Sponsoring Institution and listed in ADS.
Focus Area:*
Focus areas for non-standard training programs may be selected from an approved list. New focus areas that do not appear in the approved list are subject to approval by the ACGME.
Related Program:*
Select closely related ACGME-accredited program.
Length of NST Program (in months):*
Provide the rationale for the length of the NST program if longer than one year:*

Define the educational goals of the NST program:*
Describe NST trainee responsibilities for patient care, care management, and supervision during the NST program:*
Describe required educational experiences and didactic sessions in the NST program:*
Does the NST program require experience in patient care procedures?*

YesNo
If “Yes,” please define procedural experience requirements:*
Define the prerequisite education and/or training for entry into the NST program:*
Describe supervision of trainees in the NST program:*
Describe the method(s) for assessment of NST trainees:*
(Please ensure the note above clearly states that Milestones must be assessed within the trainee’s first three months)
Describe how personnel, clinical services, and other resources will be made available for the NST program without adverse impact on the education of residents or fellows in the Sponsoring Institution’s ACGME-accredited program(s):*
You can often find the organization that provides your program recognition and also the number associated with that program within MedHub.

From the MedHub Home Screen, you will scroll down until you find Program Accreditation. After clicking on this, at the top of the first tab, Overview, should be the information that shows your program's accreditation information.
Is the NST program accredited?*

YesNo
If "yes", identify the accrediting body:*
Is certification available to graduates of the program?*

YesNo
If "yes", identify the certifying body:*
Is this primarily a research program?*

YesNo
If “Yes,” describe how this NST program will provide advanced clinical training:*

Participating Sites for NST Program:*
Include any other training site that is associated with the program:*

Semi-Annual Evaluation:*

Blank copy of evaluation template.
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Summative Evaluation:*

Blank copy of evaluation template.
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Final Evaluation:*

Blank copy of evaluation template.
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Additional Documents:

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If this request is complete and ready to submit to NST for review, please hit submit.

If a request is submitted with incomplete information, the request could be denied which can result in a delayed response from NST.
Should be Empty:

GME Multi-Requests Form

Please reread or open the policy & procedure links!

Exceptionally Qualified Applicant Request

Program Director

Program Coordinator

CAP Request

Contact Information

Program Director

Program Coordinator

Department Chair

Program Information

You have selected "Add New Program"

Important Notice:

Proposed Changes

Funding

Department

CUH

Parkland Health

Children's Health

VA

Texas Scottish Rite

Other

Program Coordinator

Appropriate titled GME Program Coordinator FTEs

Program Director

Appropriate titled GME Program Director FTEs

All New Program submissions require a New PD Application Submission

Required Documents

All New Program submissions require a New PD Application Submission

All New Program submissions require a New PD Application Submission

New Program Director or Associate Program Director

Program Coordinator

Non-Standard Training Program Request

CAP Application

Program Information

Program Director

Program Coordinator

Primary/Core Faculty

Hospital	Fiscal Year	Preceding Budget Period
CUH	September-August	July-June
CMC	January-December	July-June
PHHS	October-September	October-September
TSRH	August-July	August-July
VA	July-June	July-June