Multi-Specialty Portfolio Program – Physician Participation and Reflection Attestation 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 NameFirst NameMiddle InitialEmail Board Certification DetailsCertifying Board Date Participation Began Date Format: MM slash DD slash YYYY Date Participation Ended Date Format: MM slash DD slash YYYY Details of the QI EffortQI Effort TitleName of QI Leader First Last Suffix Email of QI Leader Mobile Phone of QI LeaderWhat is the specific aim of the QI Effort?What was the source of the data used to measure performance in the QI Effort?What methods were used for data collection?Was the QI Effort successful in improving care for our patients?YesNoPlease explain in detail:Did the measures used address important issues for your patients?YesNoPlease explain in detail:What was your role in the QI Effort?Describe the scope of your activity/involvement in the QI Effort:If other members of your care team were involved in the QI Effort, please describe their roles and your inter-relationship with them:How would you apply what you learned in this project to your next QI Effort?ReflectionWhat change did you personally make in your practice as a result of your participation in the QI Effort?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 participatign in this QI Effort?Explain how you plan to sustain the changes you made to your practice as a result of this QI Effort:Attestation StatementAttach any relevant files regarding the QI Effort that you wish to share with the Portfolio Program Committee Drop files here or Provide additional comments here:I attest by my electronic signature below that I participated in this QI Effort 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: Date Format: 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.