MOC Participant Attestation Form Header Image

MOC Part IV Participant Attestation Form

The MOC Part IV Participant Attestation Form should be completed by a board certified physician or physician's assistant seeking MOC Part IV credit from one or more of the ABMS Member Boards participating in the CUSOM MOC Program or the NCCPA.  Applicants must have participated in an approved QI effort and have satisfied all of the participation requirements of that QI effort. The project leader of the QI effort will be contacted to confirm the applicant's participation is as stated in this form.  MOC Part IV credit will not be awarded until the project leader has verified meaningful participation on the part of the applicant.  For project leaders requesting MOC Part IV credit for themselves, please list a supervisor or another project team member to verify your participation is as stated in this form.  Please note that participating ABMS Member Board MOC fees, if applicable, must be current for the physician to receive MOC Part IV credit.  Please direct questions to the MOC Program Manager.  You may also view our program website for more information. 

Meaningful Participation Criteria:

  1. The QI effort must provide clear benefit to the participant's patients and/or be directly related to the participant's clinical practice.  
  2. The participant is actively involved in the QI effort, including participation in a minimum of 3 of the 4 activities:
    • Initial project design, including but not limited to identifying the gap in quality, development of primary outcome measures and target improvement, and development of plans for intervention
    • Implementation of strategies and interventions
    • Data collection and/or analysis to assess the impact of the interventions while making appropriate course corrections in the improvement effort
    • Participation in meetings to continue the process for improvement (documentation of meeting attendance and minutes must be available upon request, but are not required)
  3. At a minimum, the activities must be of sufficient duration to allow for participation in at least two full cycles of data assessment and planning of an improvement intervention, the implementation of a change process and re-assessment of the results (e.g., PDSA cycle) for at least six months duration.
  4. The participant is able to personally reflect on the activity, describing the change that was performed in their practice and how it affected the way care is delivered.

The timely submission of attestations is essential for participants whose certification period will end in the current year. Attestation forms must be submitted by October 28th of the current year to report credit to your ABMS specialty board or the NCCPA and have your credit count for this year.  Please note, some specialty boards (e.g., ABIM) do not accept projects older than the current calendar year.

Please allow 5 business days for your attestation to be processed; MOC Part IV credit confirmation letters will be sent to your provided email within 1-3 business days after processing.  ABMS specialty boards and the NCCPA usually process credit within 1 week of receipt from this office. The MOC Part IV point designation is decided by the specialty boards, please view each board's credit designation definition (these are subject to change). It is important to note that this project may not fulfill a participant's entire MOC Part IV requirements.  

Section 1: Participant Information

Date entered in MOCAM
Verification Obtained
Fiscal Year Reporting
Name*
Indicate your certifying ABMS Specialty Board. Please note the following boards are not participants of the MSPP Program: ABAI, ABCRS, ABNS and ABNM.
Indicate your unique specialty board identification number (please note this is not your certificate number; it’s your general ID number for the board). If you are unsure of your specialty board ID number, please contact your certifying board.
Indicate your certifying ABMS Specialty Board. Please note the following boards are not participants of the MSPP Program: ABAI, ABCRS, ABNS and ABNM.
Indicate your unique specialty board identification number (please note this is not your certificate number; it’s your general ID number for the board). If you are unsure of your specialty board ID number, please contact your certifying board.

Physician Assistants (PAs) should select "National Commission on Certification of Physician Assistants (NCCPA)" in the field ABMS Specialty Board membership and enter your NCCPA identification (ID) number in the field ABMS Specialty Board Identification Number.  

If you are unsure of your NPI number, please visit http://www.npinumberlookup.org/
Date of Birth*
University of Colorado School of Medicine (CUSOM) Affiliation*
Please note your affiliation status with the CU School of Medicine (Please select only one option).
Institution Affiliation*
Please select the physical institution at which this project was initiated/conducted.
Please describe your contribution/involvement with CUSOM and who will validate your involvement.
If the QI project originated at a non-CUSOM site, please list the name of the practice.

Section 2: Project Involvement

Example: 2018116
For umbrella projects, please list both the main project title and the specific sub-project for which you are requesting credit (e.g., NCQA PCMH – Improving Depression Screening; Target Zero – CAUTI Reduction)
Participation Start Date*
Indicate the beginning date (month & year) of your participation in the QI effort.
Participation End Date *
Indicate the ending date (month & year) of your participation in the QI effort (participation for at least six months is required). If participation is ongoing, note the current month/year.
Improvement Cycles*
Indicate how many improvement cycles you participated in (participation in at least two full cycles is required).
Meaningful Participation Activities*
Please select which activities describe your participation in the QI effort (must participate in at least 3 of the 4 activities for approval).

Section 3: Reflection

Section 4: Participant Signature

Participant Attestation Statement:  I attest I participated in this QI effort as described above.

       

Use your mouse or finger to draw your signature above
Project leader will be contacted to confirm you have participated as stated above. Project leader confirmation is required to process MOC Part IV credit with your certifying specialty board. If you are the project leader attesting to your own participation, include the email of your supervisor or another member of the project team to confirm your participation as stated above.
Save and Resume Later
Cancel
Confirm