MOC Part IV

SECTION A: Participation Information

  1. Team Leader Name:
  1. TitleofQualityImprovementProject:
  1. Location/Site(s) of the project:
  1. Your Name (Last, First, and MI):
  1. Date of Birth:
  1. Email:
  1. NPI Number:
  1. Indicate your certifying Board(s) and your Diplomate number
    Certifying Board: Diplomate/ID Number:
  1. Was this your first involvement in a Quality Improvement Initiative? Yes No
  1. Participation: Indicate the beginning date of your participation:Then indicate the end dates of two cycles in which you were participating. (Participation in at least two improvement cycles is required).

Project Participation Start Date:

Cycle 1 End Date (mm/day/yyyy):

Cycle 2 End Date (mm/day/yyyy):

In order to claim credit, you must have been actively involved in the QI effort. This includes participation in all of the following. Please confirm by marking each check box.

I worked with care team members to plan and implement interventions

I reviewed performance data to assess the impact of the interventions

I made appropriate course corrections in the improvement effort

SECTION B: Reflection

  1. Change – Describe the change that was performed in your practice and how it affected the way care was delivered.
  1. Learning – What did you learn as a result of participating in this QI effort:
  1. Sustainability – Explain how changes will be sustained as a result of this QI effort:

SECTION C: Signatures

  1. Project Participant Signature: I attest that I participated in this project as described above.

Signature:______Date: ______

(Please note: Typing your initials can be used as an electronic signature.)

QI ProjectParticipants: Save this form for your records and email a copy to your respective Project Leader for signature-approval and submission. Do not submit this form directly to the Office of CME on your own behalf. Forms submitted by participants directly will not be accepted for MOC Part IV credit awards.

  1. Project Leader Signature: I have reviewed this form and attest that the physician above has meaningfully participated in the QI effort and has met all the necessary requirements for MOC Part IV credit. I am designated by the UCSF MOC Part IV Approval Program to review and approve attestations for this QI effort. (Note: Project Leader notices of earned MOC IV credit do not need additional signatures.)

Signature:______Date: ______

(Please note: Typing your initials can be used as an electronic signature.)

Submit completed Project Design form to the UCSF MOC Project Manager .

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physician attestation FORM| Version 6.0|12.19.14