Attestation of Participation in a QI Activity for ABMS MOC Part IV

Attestation of Participation in a QI Activity for ABMS MOC Part IV

Physicians seeking Maintenance of Certification (MOC) Part IV credit through Dartmouth Health document participation by

completing this form. Other requirements to receive credit are that:

• The project lead verifies the individual’s meaningful participation

• The individual’s ABMS Member Board MOC fees, if applicable, are current

Project Information

Project title*

Dates of participation*

Participant Information

First Name*

Middle Initial*

If not applicable, enter N/A

Last Name*

National Provider Identifier (NPI) Number*

Email Address*

Date of Birth*

Certifying Primary Board(s)

Indicate the first primary board in which you certified. The American Board of:*

Select

What is your unique Board identification number?*

If you have a subspecialty certification(s) in that Board, please list it.

Second certifying primary board – if applicable.

Select the name of the second primary board in which you certified.

Select

What is your unique identification number for this secondary Board?

If you have subspecialty certification(s) in this secondary board, please list here.

Participation

In this data-guided quality improvement activity, I affirm that I participated in the following activities, which are expected of all participants to receive MOC Part IV credit:*

Select

Reflections

Change. What change did you personally make in your practice?*

Impact. How did this affect your practice?*

Learning. What did you learn as part of participating in this QI activity?*

Sustainability. Explain how you plan to sustain the changes you made to your practice as a result of this QI activity.*

I attest that all information is truthful and correct. I affirm my participation in these activities.*

Select

Send me a copy of my responses

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