Baylor College of Medicine s1

Baylor College of Medicine Graduate Medical Education

New Program Director Submission Form

Program Name/Number

Current Program Director

Proposed Program Director

Chairman Confirms:

 Applicant Meets all ACGME/RRC Requirements for Program Director  Applicant Meets all Specialty Board Requirements for Program Director  Department has Provided ______% of Protected Time for Position  Department has Established Salary Source for Protected Time Not Based on Applicant’s Clinical/Research Productivity  CV Attached

Effective Date

Date first appointed as Faculty Member?

Proposed Program Director’s Email address Is the Current Program Director remaining in program as faculty?

Chairman’s Signature/Date

Current Program Director’s Signature/Date

Proposed Program Director’s Signature/ Date Dean/Designee Signature/Date