1. Resident/Fellow Complement Change Request (insert Program Name)

2. (insert Program Name)
(Permanent or Temporary) Increase
Current number of (residents or fellows):(insert #)
Increase request to: (insert #)
Effective Date: (insert date)

3. Educational Rationale for Complement Change Request: (please give a brief overview of rationale)

4. Major Changes…..
(list major changes to program leadership and facilities)

5. Citation Update……
(Insert a brief update on each citation if applicable. If your program has no citations, please report no citations were issued as of this date)

6. (Briefly describe specific circumstances for the change and the provisions (funding) to insure adequacy of the change. Note: The rationale must be exclusively educational and not based on specialty demands)

7. Thank you for your consideration.