ATC Fellowship Program Change Request Form AHNS Advanced Training Council Fellowship Program Change Request Form Change Request Forms must be submitted by November 1 in order to be considered for the next year’s fellowship matchProgram InformationProgram Name:*Program Director Name:*Program Director Phone:*Program Director Email:*Number of Fellows the program is currently accredited for:*Current Program Accreditation Type:* Head & Neck EndocrineProgram Change InformationPlease complete any of the following that apply: Request for Non-Participation in the 2018 Fellowship Match Change in Program Director Significant Change in Faculty Complement Reduction in Number of Positions Available. Increase requests must be made by July 1, at the close of the previous year’s fellowship match. Increase in Number of Positions Available - Requests to increase the number of fellowship positions may require a site visit by the ATCPlease cite your reasons for not participating in the space provided below.Who will be taking over as Program Director? Will this Program Director be permanent or interim?Will the original Program Director be leaving the health system completely?Will there be any additional changes in faculty?How will this impact the fellowship program in terms of case volume, rotations, curriculum, etc?What is the formal plan of action for the current and incoming fellows?Has the current and incoming fellow been notified?Please attach any supporting documentation HERE Drop files here or Please answer the questions below and/or provide supporting documentation that this change will not adversely affect the fellowship. For example, case volume of supporting faculty. How will this impact the fellowship program in terms of case volume, rotations, curriculum, etc?Please attach any supporting documentation HEREPlease cite the reasons for the reduction in positions and how it will affect the program using the space belowPlease cite the reasons for the increase in positions and how it will affect the program using the space below.Potential Triggers for a site visit by the Accreditation Committee include but are not limited to: a change in Program Director, a change in the number of fellows, a significant change in the associate faculty, insufficient case logs, program complaints, failure to address previous citations, and conflicts with the residency program.* I understand that the above information will be circulated to the AHNS Advanced Training Council for review and that all changes must be approved by the Council.