GMEC & CAP Application

CAP & GMEC Requests

Complete this application to submit your request to the CAP subcommittee and GMEC

Timeline
CAP meets on the last Monday of the months listed below. The deadline to submit CAP applications is ten business days prior to the upcoming CAP meeting.

GMEC meets on the first Monday of the months indicated in the table below.

CAP (last Monday)	GMEC (first Monday)
June	July
July	August
September	October
October	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	FTE Requests Due Date
CUH	September-August	March 1
CMC	January-December	April 1
PHHS	October-September	April 1
TSRH	August-July	May 1
VA	July-June	August 31

CAP/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.

Review and Recognition Committee Meeting (RRC)

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?*

CAP RequestExceptionally Qualified Candidate 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 prior to completing this form.

(Not available to fellowships in Neurology, Ob-Gyn, 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 Director's Name:*

First NameLast Name
Program Director's Email:*
example@example.com
Program Coordinator's Name:*

First NameLast Name
Program Coordinator's Email:*
example@example.com
Applicant Name:*

First NameLast Name
Program:*
Expected PGY Level:*
Please upload the applicant's current CV:*

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Please upload the applicants Step 1 USMLE/COMLEX Scores:*

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Please upload the applicants Step 2 USMLE/COMLEX Scores:*

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Please upload the applicants Step 3 USMLE/COMLEX Scores:*

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Please upload the applicants ECFMG certificate:*

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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.*

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Additional document information:

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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 six 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.
Date:*

MonthDayYear
Date

New Program Director or Associate Program Director
Please review the GME Program Directors Procedure prior to completing this form.
Is this request for a new _________?*

Program Director (PD)Associate Program Director (APD)
Name of Nominee:*

First NameLast Name
Nominee's Email:*
example@example.com
Appointment Date:*
Program:*
Program Coordinator's Name:*

First NameLast Name
Program Coordinator's Email:*
example@example.com
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
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Nominee's Current CV:*

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Date:*

MonthDayYear
Date

Proposed Changes

Section 2 of 6
For this section:
- Specify the planned implementation date for the proposed actions, assuming all necessary approvals are secured.
- Note that actions impacting other programs will require a separate CAP application.
- 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.
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:

Changes Explained

Section 3 of 6
For this section:

• 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.).
Affiliated Institutions (select all that will be affected by any proposed changes or the addition of the new program):*

University HospitalsParkland HealthChildren's HealthVeteran's Affairs Medical CenterOther
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:*
This may involve exposing residents to new technologies and creating rotations that enhance or broaden their educational experiences. Provide a detailed implementation plan, ensuring the rationale is solely educational and not driven by specialty-specific demands.
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.
Does your program have a key faculty requirement?*

YesNo
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)

Funding

Section 4 of 6
For this section:

• Most CAP applications will require detailed funding information to be provided.
• Confirmation of financial support signed by the person authorized to commit funds will be required for each site that will be supporting the requested activity.
• Financial requests should be negotiated in advance with hospitals according to their budget cycles, which is shown below. Please plan accordingly.

Hospital	Fiscal Year	FTE Requests Due Date
CUH	September-August	March 1
CMC	January-December	April 1
PHHS	October-September	April 1
TSRH	August-July	May 1
VA	July-June	August 31

Specify percentage of funding from all sources for this request: *

	Percentage of Program Funding (Must Total 100%)
Department
CUH
Parkland Health
Children's Health
VA
Grant (1)
Grant (2)
Other

Total Funding Percentage:
This must equal 100%
Funding more than 100%

Funding totals cannot exceed 100%, please recalculate.
One email and funding source is required. However, you can list up to 7 funding sources if needed.

Main Funding Contacts:
- Parkland: Elizabeth Ponce - elizabeth.ponce@phhs.org or Joseph Chang - joseph.chang@phhs.org
- CUH: Curtis Pullman - curtis.pullman@utsouthwestern.edu or Chris Rubio - chris.rubio@utsouthwestern.edu
- Children's: Jamiese Harris - jamiese.harris@childrens.com
- VA: Jamila Jackson - jamylahk.jackson@va.gov
- Department: The Department Chair only, not the division chief/chair
Please upload the funding approval letter or approval email from the main funding contact(s), grant information, or other sources of funding.

Click here for help understanding Funding Source Information chart
1. The Effective Date will often be the same as the Effective Date of Proposed Change. This may coincide with the fiscal year/cycle of that funding source. This should be discussed or conferred with the funding source to assure this is correct.
2. Please provide the Current Approved FTE.
3. The Additional FTE will be how many FTEs you are adding to this funding source. If you already request 20 FTE from a funding source, and your changes will require an additional 1, a total of 21 FTE, then you will only need 1 additional FTE.
4. PY will be all of the Program Years this additional FTE will cover. This could be 1 program year, PY1, or it could cover all program years, PY1-3. This is the program year, not the post-graduate year (PGY).

Funding Source
Funding Source Information*
1st Funding Source:*
Funding approval letter, approval email, grant information, or other funding information:*

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2nd Funding Source:
Funding approval letter, approval email, grant information, or other funding information:*

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3rd Funding Source:
Funding approval letter, approval email, grant information, or other funding information:*

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4th Funding Source:
Funding approval letter, approval email, grant information, or other funding information:*

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5th Funding Source:
Funding approval letter, approval email, grant information, or other funding information:*

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6th Funding Source:
Funding approval letter, approval email, grant information, or other funding information:*

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7th Funding Source:
Please upload the funding approval letter or email from the main funding contacts:*

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Does your department currently have enough titled GME Program Coordinator FTEs to support this program and/or the changes proposed?*

YesNo
Please list the total proposed FTE coverage for the designated Program Coordinator, including all programs they are assigned to:*
(ex. proposed changes is an additional .5 FTE but the PC is designated as the PC to another program at .5 FTE, enter 1.0 FTE)
Does your department currently have enough titled GME Program Director FTEs to support this program and/or the changes proposed?*

YesNo
Please list the additional FTE required for the Program Director's support:*
Appropriate titled GME Program Coordinator FTEs

You indicated your department currently does not have the appropriate amount of titled GME Program Coordinator FTEs to support this program. Please understand without adequate Program Coordinator support, GMEC may deny your request until a properly titled GME Program Coordinator has been hired to fulfill the FTE requirement.
Appropriate titled GME Program Director FTEs

You indicated your department currently does not have the appropriate amount of titled GME Program Director FTEs to support this program. Please understand without adequate Program Director support, GMEC may deny your request until a properly titled GME Program Director fulfilled the FTE requirement.

Required Documents

Section 5 of 6
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 you do not have, for a legitimate reason, a required document, you can upload a Word document explaining in detail why the program does not have the required and 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.
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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Supervision Grid:*

Used for: New ACGME, New TMB, Renew TMB, New Other
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Competency-Based G&O:*

(Must be Site Specific) 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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Additional Documents:

Used for: Any additional documents the program might want to include (not required)
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Application Preparation and Approval

Section 6 of 6
For this section:
- Application Preparation and Approval
- Include the name of the individual that prepared the CAP application
- Program Coordinator’s email
- Program Director’s email
- Core Program Director’s email (if applicable)
- Department Chair email
This application was prepared by:*

First NameLast Name
Submission Date:*

MonthDayYear
Date
Program Coordinator's Email:*
example@UTSouthwestern.edu
Program Director's Email:*
example@UTSouthwestern.edu
Is this application for a fellowship?*

YesNo
Core Program Director's Email:*
The department's main residency PD
Department Chair Email:*
Must be the department, not division chief's email.
Date:*

MonthDayYear
Date
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.
Should be Empty:

CAP & GMEC Requests

Please reread or open the policy & procedure links!

Exceptionally Qualified Applicant Request

New Program Director or Associate Program Director

CAP Request

Program Information

Proposed Changes

Changes Explained

Funding

Funding more than 100%

Appropriate titled GME Program Coordinator FTEs

Appropriate titled GME Program Director FTEs

Required Documents

Application Preparation and Approval