American Board of Pediatrics (ABP) Part 4 Maintenance of Certification (MOC)

QI Project Enrollment Form

Complete the information below to request enrollment in a currently approved project. Completion of this form does not verify acceptance. You will be contacted by the project leader or the MOC Portfolio Administrator with additional information. Incomplete or insufficient information may delay approval for participation in the project. Please allow up to 1 week to receive a response regarding your form submission.

Currently Approved Individual Projects

Project	Enrollment Cut-Off Date
Bronchiolitis (for the outpatient setting)	Open
Pneumonia (for the outpatient setting)	Open
Assessing and Improving Physician Wellness	Open

Question Title

* 1. Which project would you like to join?

Question Title

* 2. Please provide the following demographic information.

First Name

Last Name

Degree and Credentials

Email Address

Phone Number

Practice/Organization Affiliation

Question Title

* 3. MOC project participation at ETCH requires completion of the Institute for Healthcare Improvement (IHI) Open School Online Course: QI 102: How to Improve with the Model for Improvement.

I have already submitted my certificate of completion.

I will attach my certificate of completion to this form.

I will email my certificate of completion to the MOC Portfolio Administrator later. I understand that submitting my certificate of completion is required for project participation.

Question Title

* 4. Upload your IHI QI 102 certificate of completion.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Contact the MOC Portfolio Administrative team with any questions: CME@etch.com