GME Program Change Letter of Intent

Program Name

Program Director Name

Program Director Email

Date of Submission

Proposed GME Program Change (select all that apply)

New ACGME-accredited program  

New rotation site  

Complement/FTE increase  

New elective or track  

Training extension of more than 3 months (e.g., leave, remediation)

OtherOther

Is this request temporary or permanent?

Temporary

Permanent

Anticipated duration of temporary request

What is the funding source for this request?

No additional funding required – (e.g., rotation changes do not result in a funding ask but may reallocate existing funding at a site)  

Fully funded by UW School of Medicine department

Fully funded by outside entity (e.g., VA, military, grant)

Requesting institutional/hospital support

Please upload confirmation of funding

Maximum file size: 52.22MB

Requesting institutional/hospital support from (select all that apply)

How much additional FTE is being requested?

Include number of residents/fellows, training year(s), and estimated FTE per year or per site, if applicable.

Will this request result in any FTE no longer being utilized?

Yes

No

Include number of residents/fellows, training year(s), and estimated FTE per year or per site. 

Briefly describe the nature of the proposed change, including type (e.g., new rotation, expanded FTE, new track), scope, and anticipated timeline.

What Problem or Need Does This Address? (Select all that apply)

Educational gap or unmet training need

Accreditation requirement or risk mitigation

Strategic growth or program expansion

New technology, opportunity, or institutional priority

Clinical service/staffing need

Faculty availability or development

Space, scheduling, or resource constraints

OtherOther

Please elaborate on the predominant problem or institutional need addressed by this request (1-2 paragraphs).

What sites, services, or departments will be involved or impacted? 

Include relevant sites, services, or departments that will be impacted or required for implementation.

Have you discussed this with all relevant stakeholders (e.g., Core Program Director, Department Chair, Division Head, etc.)?

If your program has any of these roles, please ensure you’ve discussed the proposal with them.

Yes

No

Name of Department Chair who was notified of this proposal (required for all applications)

Name of Department Vice Chair for Finance and Administration who was notified of this proposal (required for all applications)

Please list the names and roles of additional stakeholders who were notified of this proposal (if applicable)

e.g., Department Vice Chair for Education, Core Residency Program Director, etc.

Questions?