Programa de trabajo de especialidades múltiples – Testimonio de participación y reflexión de los médicos This attestation must be completed by each certified physician seeking MOC Part IV credit from one of more of the participating ABMS Member Boards. The physician must have participated in an approved QI Effort and have satisfied all of the participation requirements of the QI Effort. This attestation must also be "cosigned" (an electronic form is provided for this purpose) by the project leader, as determined by the Portfolio Sponsor. The completed and signed attestation will be retained by the Portfolio Sponsor who will notify the Portfolio Program of the physician's completion of the QI Effort. Please note that participating ABMS Member Board MOC fees, if applicable, must be current and are the responsibility of each member physician, in order for the physician to receive MOC Part IV credit.Physician Participant Seeking MOC Part IV CreditLast Name First Name Middle Initial Email Birthdate MM slash DD slash YYYY HiddenBoard Certification DetailsCertifying Board Board Certification DetailsCertifying BoardAmerican Board of Allergy and ImmunologyAmerican Board of AnesthesiologyAmerican Board of Colon and Rectal SurgeryAmerican Board of DermatologyAmerican Board of Emergency MedicineAmerican Board of Family MedicineAmerican Board of Internal MedicineAmerican Board of Medical Genetics and GenomicsAmerican Board of Neurological SurgeryAmerican Board of Nuclear MedicineAmerican Board of Obstetrics and GynecologyAmerican Board of OphthalmologyAmerican Board of Orthopaedic SurgeryAmerican Board of OtolaryngologyAmerican Board of PathologyAmerican Board of PediatricsAmerican Board of Physical Medicine and RehabilitationAmerican Board of Plastic SurgeryAmerican Board of Preventive MedicineAmerican Board of Psychiatry and NeurologyAmerican Board of RadiologyAmerican Board of SurgeryAmerican Board of Thoracic SurgeryAmerican Board of UrologyNational Commission on Certification of Physician AssistantsDetails of the QI ActivityDate Participation Began MM slash DD slash YYYY Date Participation Ended MM slash DD slash YYYY QI Activity TitleName of QI Leader First Last Suffix Email of QI Leader Mobile Phone of QI LeaderWhat is the specific aim of the QI Activity?What was the source of the data used to measure performance in the QI Activity?What methods were used for data collection?Was the QI Activity successful in improving care for our patients? Yes No Please explain in detail:Did the measures used address important issues for your patients? Yes No Please explain in detail:What was your role in the QI Activity?Describe the scope of your activity/involvement in the QI Activity:If other members of your care team were involved in the QI Activity, please describe their roles and your inter-relationship with them:How would you apply what you learned in this project to your next QI Activity?ReflectionWhat change did you personally make in your practice as a result of your participation in the QI Activity?Describe the impact this has had on your practice:Further describe any anticipated impact this may have on your practice in the future:What did you learn as a result of participating in this QI Activity?Explain how you plan to sustain the changes you made to your practice as a result of this QI Activity:Attestation StatementAttach any relevant files regarding the QI Activity that you wish to share with the Portfolio Program Committee Drop files here or Select files Max. file size: 50 MB. Provide additional comments here:I attest by my electronic signature below that I participated in this QI Activity as described above and agree that my QI Leader will review this attestation and affirm that I was an active participant in this QI Effort and have met all of the requirements for MOC Part IV credit. Date submitted: MM slash DD slash YYYY If the Submit button below is dimmed, you have not fully completed the application. Please review the form for any required fields (with a red asterisk) that you may have missed.