NON-AACS ACCREDITED FELLOWSHIP CHECKLIST

AMERICAN BOARD OF COSMETIC SURGERY CHECKLIST FOR NON-AACS FELLOWSHIP

Petition of Equivalency: Initial certification by an Approved Board Recommendation letter from Fellowship Director Copy of certificate of completion of fellowship program identifying training Address and phone number of Fellowship Program Sponsoring entity Address and phone number of Fellowship Program Surgical operative logs during fellowship training (300 minimum procedures) Non-refundable Application Fee in the amount of $500.00

______ ______ ______ ______ ______ ______ ______

Non-AACS Accredited Fellowships:

Certificate, letter or independent evaluation that the fellowship has completed formal accreditation site visits by their primary organization (i.e. AAOMS, AAFPRS, AAD, ASPS or any ACGME or COPT, ACOS or ASOPRS program)

______

Non-AACS, Non-Accredited ACGME (or equivalent) Fellowships: Successful completion of any program not listed above Copy of TJC or AAAHC Certification Copy of Faculty hospital privileges or AAAHC or TJC facility privileges Copy of Program's written goals and objectives for fellows (i.e. journal review, research, number of days/hours required to complete fellowship, etc.) List of all active faculty (no less than 3) and their academic appointments Academic training schedule (including didactic sessions, resources, etc.) University affiliation _____ YES _____ NO. If yes, name _________________________

______ ______ ______

______ ______ ______

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Copies of additional information are only required if training program utilizes two or more institutions for fellowship training purposes. (Not applicable if fellows train at only one institution):

Designation of a program director at that site with delineation of their authority

Designation of all teaching faculty at that site that will be participating in fellowship training

Expected contribution to the fellowship training program

Period of assignment that fellows will spend at the institution

Institution's financial commitment to the direct support of the fellowship program

Primary sponsor accepts full responsibility for the quality of education provided in affiliated institutions

All standards applicable to the primary institution are applicable to the training provided in affiliated institutions

______ ______ ______ ______ ______

______

______

APPLICANT'S NAME: __________________________________________________

L:\ABCS\Fellowships\Non-AACS Fellowship Checklist - Updated 8-1-13.doc

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