Short-Term Provider Application Packet

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1 Short-Term Provider Application Packet For education providers seeking Continuing Education Recognition Points (CERPs) for their educational activities As an International Organisation, IBLCE uses British English in its publications.

2 Table of Contents What is IBLCE?... 3 Contact Information... 3 Introduction... 3 STP Application Form... 4 STP Program Content Form... 8 Speaker Disclosure & Conflict of Interest Declaration Form STP Application Checklist STP Payment Form 12 Fee Schedule...13 STP Application Packet July 31, of 15

3 What is IBLCE? IBLCE or the International Board of Lactation Consultant Examiners is the independent international certification body conferring the International Board Certified Lactation Consultant (IBCLC ) credential. Contact Information International Board of Lactation Consultant Examiners (IBLCE) Democracy Lane, Suite 400 Fairfax, Virginia USA Phone: Fax: IBLCE has offices in Austria, Australia and the United States. To reach the IBLCE office that serves your country, use the following addresses. North America, South America and Israel: Europe, the Middle East (except Israel) and the countries of North Africa: europe.org Asia Pacific and African countries (not served by the European office): Introduction Individuals, independent educators, hospitals, academic institutions and professional associations are among the types of entities that can become Short-Term Providers (STP) of IBLCE CERPs recognised educational activities. STPs must submit each educational activity to IBLCE for consideration and may not recognise their own educational activities with IBLCE CERPs unless verified by IBLCE. IBLCE has the sole authority to review and recognise educational activities provided by STPs with IBLCE CERPs. Short Term Providers are expected to adhere to the IBLCE Minimising Commercial Influence on Education Policy. STP Application Packet July 31, of 15

4 Short-Term Provider Application Form Name of Provider: Provider Website: Provider Phone: Name of Designated Contact Person: Contact Phone: Contact Name of Education Program: City and State/Province: Country: Language of Program: Date(s) of Program: Choose the ONE option that best describes the learning format of your education program. Live, in-person Web-based Audio only Recording Other (please specify) Choose the ONE option that best describes the amount of CERPs you are requesting. up to and 4 CERPs up to and 8 CERPs up to and 16 CERPs up to and 24 CERPs Over 24 CERPs Professional Education Group Choose the ONE option that best describes your primary audience, keeping in mind that CERPs are intended for individuals who are already certified as an IBCLC. IBCLCs Mix of IBCLCs and Others Has this program been recognised for CERPs in the past 12 months? Yes No If Yes keep in mind that STP recognition of CERPs is valid for 12 months. There is no need to reapply for CERPs if you are repeating a program that was already recognised for CERPs within the past 12 months. Choose the ONE option that best describes the program s speaker(s) disclosure of actual or potential competing interests or affiliations. No speakers have indicated actual or potential competing interests or affiliations in relation to any presentation(s) in this program. Speaker(s) have indicated actual or potential competing interest or affiliations in relation to presentation(s) in this program. The speaker(s) have been given a disclosure statement to complete and sign. I/We have retained the completed and signed Declaration of Competing Interest Form(s) I/we have indicated below how the program attendees will be notified. Program Attendee Notification Method: 4 of 15 STP Application Packet July 31, 2016

5 Short-Term Provider Disclosure Statement: Please read the following Short-Term Provider (STP) Disclosure Statement carefully. In order for your program to be recognised for CERPs, you must agree to the terms of this disclosure statement by signing and dating this form. Violations of the terms and conditions of this statement are considered unprofessional and could result in denial, forfeiture or revocation of your STP status. As the education provider, I/we wish to apply for (program name) to be recognised with IBLCE Continuing Education Recognition Points (CERPs). I/We acknowledge, understand and agree that: STPs must complete the STP application and submit it to IBLCE with the applicable fee. Abide by the IBLCE Minimising Commercial Influence on Education Policy. STP may not be a company or commercial interest as defined by the IBLCE Minimising Commercial Influence on Education Policy. The educational activity must be intended as professional education for IBCLCs. STPs are advised to take care that the programs for which recognition is being sought are relevant to the continued learning needs of IBCLCs. Refunds will not be given if the programs submitted by STPs do not meet the continued learning needs of IBCLCs. For the benefit of IBCLCs, education providers are required to distribute certificates of completion that show the number of IBLCE CERPs recognised, name of the program, name of the participant, date of the program, and program coordinator name or signature. All program speakers/presenters must complete a Speaker Disclosure and Conflict of Interest Form and declare any affiliation or conflict of interest that might impair the objectivity of the information they present. All such affiliation or conflict of interest must be brought to the attention of the participants as outlined in the IBLCE Minimising Commercial Influence on Education Policy. The STP must comply with all reporting requirements established by IBLCE and must cooperate with any audits conducted by IBLCE within the given timeframe. If the print or web-based promotional materials were finalised prior to the notification of IBLCE CERPs recognition, the STP must submit a copy of these promotional materials with their CERPs application. Promotional materials that are finalised prior to IBLCE CERPs recognition may state that application has been made for IBLCE CERPs recognition; however, these promotional materials may not state how many IBLCE CERPs have been requested. If the print or web-based promotional materials are finalised after the notification of IBLCE CERPs recognition, the STP must submit a copy of the finalised promotional materials within 30 days of the date on which each IBLCE CERP recognised educational activity was offered. Promotional materials that are finalised after IBLCE CERPs recognition may state how many IBLCE CERPs were recognised for each educational activity on the program. Without the express written consent of IBLCE, the STP may not use the IBLCE logo on any of their publications and/or promotional materials regardless of the format and 5 of 15 STP Application Packet July 31, 2016

6 manner of the publication or material. The STP must retain all program documentation, attendance rosters, for at least 6 years following the last date the educational activity was offered. If the attendee misplaces their certificate it is the responsibility of the attendee and the STP to organise a replacement certificate/verification. IBLCE will under NO circumstance provide any form of confirmation that attendee was present at the education. STPs who do not comply with IBLCE requirements will be notified by IBLCE staff. Such notification is intended to be informative of processes and procedures and providers are expected to cooperate. If a second notice is required, the provider may be required to verify that corrective action has been taken. If a third notice is required, suspension or revocation of STP status may be imposed. To the best of our knowledge, I/we declare that: No part of the above program is organised by a Company as defined in the IBLCE Minimising Commercial Influence on Education Policy. No such Company or Company personnel have had or will have input into the choice of speakers/presenters or topics or into the content of the above program. Please Note: Your original signature is required. Typed signatures are not acceptable. Signature: _ Date: Printed Name: Position/Title: 6 of 15 STP Application Packet July 31, 2016

7 For Independent Study Modules (ISM) ONLY: ISMs must be pre-tested to determine how long it takes to complete the ISM and to detect and correct any problems with the ISM and/or ISM post-test (if applicable). Alternatively, if the ISM has been recognised by another professional organisation for continuing education credit this information may be used. Please provide the following information: If tested, average amount of time needed to complete the ISM: Were any problems with the ISM and/or post-test identified? Yes No If Yes, were the problems corrected before submitting the ISM for CERP recognition? Yes No Has this ISM been recognised by another organisation for professional continuing education credit? Yes No If yes, which organisation; how many credits were awarded ; and how many minutes does one continuing education credit equal? STP Application Packet July 31, of 15

8 STP Program Content Form To be completed and sent with STP Application Form Name of Program Provider: Date(s) of Program: Title of Program: For each session on the program, breaks, provide the following information. If additional space is needed, please make copies of this form. Session Title Start Time Speaker Number & Content Abstract IBLCE Detailed Type **To ensure proper Content of recognition of Outline End Time CERPs CERPs, be as Discipline(s) Covered [For specific as possible Office Use Only] Length Delivery Type (e.g. inperson, web-based, ISM) STP Application Packet July 31, of 15

9 Independent Study Module Review Form for Short-Term Providers ISMs must be reviewed by 2 or more subject matter experts prior to pre-testing by a minimum of 5 IBCLCs to establish time allocation and test validity. Please note: If continuing education units from another organisation have been awarded this pre-testing process does not need to be completed. Providers, please complete the following questions. Name of ISM # and Type of CERPs Assigned Date CERPs Assigned Has this ISM been awarded continuing education units by another organisation? Yes No If Yes, how many units? and How many minutes does each continuing education unit equal? After, completing the above questions, please distribute copies of this form, if necessary, to document the information from the review and pre-testing processes. Name of Reviewer: Reviewer Please check the appropriate category IBCLC Reviewer Subject matter expert reviewer Were any problems discovered with the module? Yes No Were the problems resolved? Yes No How long, from start to finish, did it take for you to complete your review of the ISM? minutes Reviewer Signature: Date: Providers should retain this completed form. In the event IBLCE audits an ISM, this form will be required 9 of 15 STP Application Packet July 31, 2016

10 Speaker Disclosure & Conflict of Interest Declaration Form Providers: It is the responsibility of the Program Provider to distribute, collect and retain completed Speaker Disclosure & Conflict of Interest Declaration Forms from each speaker on the provider s program schedule. Furthermore, it is the Program Provider s responsibility to print any disclosures made by Speakers in the program materials and to provide IBLCE, upon request, with copies of the completed disclosure forms. Name of Provider: Name of Program: Program Date(s): It is the policy of IBLCE to make best efforts to insure balance, independence, objectivity, and scientific rigor in educational activities which are recognised for IBLCE Continuing Education Recognition Points (CERPs). All speakers/presenters participating in any program recognised for IBLCE CERPs are expected to disclose to the program audience any affiliations that may have a bearing on the subject matter of their presentation. Such affiliations include, but are not limited to: Companies and commercial entities as defined in the IBLCE Minimising Commercial Influence on Education Policy Any other persons or entities related to the subject matter of the presentation topic or the general topic of the program as a whole. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any potential competing interest shall be identified openly so that participants may form their own judgments about the presentation with the full disclosure of pertinent facts. The participants will determine whether the speaker s competing interests may reflect a possible bias in either the exposition or the conclusions presented. Speaker s Individual Declaration of Competing Interest or Affiliation Speakers: Please read the above policy and then provide the following information. Promptly return the completed form to the Program Provider. Name: I have no actual or potential declarations to make in relation to this program. I have a competing interest or affiliation that could be perceived as having a bearing on my presentation. I have listed all current competing interests or affiliations below. Competing Interest or Affiliation* Name of Person/Organisation Signature: Date: *Possible types of affiliations include: grant/research support; receipt of honoraria, travel, or other benefits; acting as a consultant/independent contractor, employee, officer or director, or having a financial interest; participation as part of a speaker s bureau or being a regular contributor to a publication; having a close friend or family member who is an officer, director, employee, or who has a financial interest; and any other financial or material support. STP Application Packet July 31, of 15

11 STP Application Checklist When applying to be a STP, all of the following materials MUST be sent to IBLCE, along with payment. Incomplete applications are subject to delays in processing. Complete applications will be reviewed in the order in which they are received. All educational activity types are required to submit the information shown below. Completed STP Application Form that is signed and dated Completed STP Program Content Form or equivalent information that shows each program session content abstract Copy of program print or web-based promotional materials Completed STP Payment Form and payment For ISMs, Instructions for the learner about how to complete the ISM and submit the post-test for grading For web-based or ISM programs, a copy of the post-test which is composed of multiple choice and/or true-false questions, along with the answer key and the pass-fail standard or for a web-based program(s), instead of a post-test, evidence of a system for tracking attendee access and evidence of using this information to award certificates of completion For ISMs, if applicable, documentation that the ISM has been awarded continuing education units from another organisation, along with information on how those continuing education units are calculated. Please Note: If an ISM has been approved for continuing education units (CEUs, CMEs etc.) by another professional certifying body, IBLCE may accept the number of units assessed for the ISM by that body as equivalent to the number of CERPs. STPs should mail or fax the completed application and payment to the regional office that serves the country in which the STP is located. The regional office contact information can be found on the IBLCE website at Please Note: All documents STP Application Form, STP Program Content Form and STP Payment Form and payment must be sent together. Incomplete and incorrectly submitted applications may take longer to review. Applications may be submitted by mail or fax; please do not send both ways. STP Application Packet July 31, of 15

12 STP Payment Form Name of Provider: Name of Program: Program Date(s): Country Fee Tier (choose 1. See next page): Tier 1 Tier 2 Tier 3 Fee Calculation: One CERP is equal to 60 minutes of education. To calculate your fee, divide the total number of program minutes by 60 minutes. For example a 4 hour program would be 240 program minutes or 4.0 CERPs. Calculation of conference schedules with concurrent breakout sessions must include all program minutes for the purposes of payment. In the example shown below, an attendee would receive 2.75 CERPs; however, the program would be recognised for 4.75 CERPs and the CERPs review fee would be based on 4.75 CERPs. Sample Conference Schedule Attendee Minutes Program Minutes 60 minute plenary session choices of 60 minute concurrent breakout sessions 45 minute closing plenary session Total 165 (2.75 CERPs) 285 (4.75 CERPs) Total Number of Program CERPs: Please indicate your choice and method of payment. I/We wish to submit all required paperwork by fax and will pay by credit card. OR I /We wish to submit all required paperwork by mail and will pay using, a credit card. Application Submission and Payment Terms: I/We must send the signed STP Application Form, the STP Program Content Form and STP Payment Form, with all required credit card information. Furthermore, I/we understand and agree that, if payment is not included, the application for CERP approval will not be reviewed until payment is received. If my/our credit card is associated with another currency, I/we understand and agree that I/we are subject to charges associated with currency exchange transactions. Signature Date Credit Card: MasterCard Visa American Express Discover (American Express and Discover cards are ONLY accepted in the Americans region) Credit Card Number Expiration Date Verification No: Total amount to be charged on credit card (please list currency): $ (See fee schedules) Printed Name of Cardholder_ Signature of Cardholder: Postal Code of Cardholder: Cardholder Telephone: STP Application Packet Last updated July of 15

13 2017 Fee Schedule for Short-Term Providers Located in Tier 1 Countries Tier 1 Andorra, Aruba, Australia, Austria, Bahrain, Belgium, Bermuda, Brunei Darussalam, Canada, Cayman Islands, Cyprus, Czech Republic, Denmark, Equatorial Guinea, Estonia, Falkland Islands, Finland, France, French Polynesia, Germany, Gibraltar, Greece, Greenland, Guadeloupe, Guam, Hong Kong, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kazakhstan, Kuwait, Liechtenstein, Lithuania, Luxembourg, Macau, Malaysia, Malta, Martinique, Monaco, Netherlands, New Caledonia, New Zealand, Norway, Oman, Poland, Portugal, Puerto Rico, Qatar, Reunion, San Marino, Saudi Arabia, Seychelles, Singapore, Slovakia, Slovenia, South Korea, Spain, St. Maarten, Sweden, Switzerland, Taiwan, Trinidad and Tobago, United Arab Emirates, United Kingdom, United States, Virgin Islands (British), Virgin Islands (US) *If your country is not listed, please contact IBLCE at Currency 4 CERPs 8 CERPs 16 CERPs 24 CERPs Over 24 CERPs Professional Education Group USD $55 $90 $140 $200 $265 $185 EUR AUD $73 $119 $185 $264 $350 $244 STP Application Packet Fees updated on August 31, 2016 July 31, of 15

14 2017 Fee Schedule for Short-Term Providers Located in Tier 2 Countries Tier 2 Albania, Algeria, American Samoa, Angola, Anguilla, Antigua and Barbuda, Argentina, Armenia, Azerbaijan, Bahamas, Barbados, Belarus, Belize, Bhutan, Bosnia and Herzegovina, Botswana, Brazil, Bulgaria, Chile, China, Colombia, Cook Islands, Costa Rica, Croatia, Curacao, Dominica, Dominican Republic, Ecuador, Egypt, El Salvador, Fiji, Gabon, Georgia, Grenada, Guatemala, Indonesia, Iraq, Jamaica, Jordan, Kosovo, Latvia, Lebanon, Libya, Macedonia, Maldives, Mauritius, Mexico, Mongolia, Montenegro, Montserrat, Morocco, Namibia, Northern Mariana Islands, Palau, Panama, Paraguay, Peru, Romania, Russian Federation, Serbia, South Africa, Sri Lanka, St. Kitts and Nevis, St. Lucia, St. Martin, St. Vincent and the Grenadines, Suriname, Swaziland, Thailand, Tunisia, Turkey, Turkmenistan, Ukraine, Uruguay, Venezuela *If your country is not listed, please contact IBLCE at Currency 4 CERPs 8 CERPs 16 CERPs 24 CERPs Over 24 CERPs Professional Education Group USD $35 $55 $90 $110 $175 $90 EUR AUD $47 $73 $119 $146 $231 $119 STP Application Packet Fees updated on August 31, 2016 July 31, of 15

15 2017 Fee Schedule for Short-Term Providers Located in Tier 3 Countries Tier 3 Afghanistan, Bangladesh, Benin, Bolivia, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Cote D Ivoire, Democratic Republic of the Congo, Djibouti, Eritrea, Ethiopia, Federated States of Micronesia, Gambia, Ghana, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Kenya, Kiribati, Kyrgyzstan, Laos, Lesotho, Liberia, Madagascar, Malawi, Mali, Marshall Islands, Mauritania, Moldova, Mozambique, Myanmar (Burma), Nepal, Nicaragua, Niger, Nigeria, North Korea, Pakistan, Papua New Guinea, Philippines, Republic of the Congo, Rwanda, Samoa, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sudan, Syria, Tajikistan, Timor-Leste, Togo, Tonga, Tuvalu, Uganda, United Republic of Tanzania, Uzbekistan, Vanuatu, Viet Nam, Western Sahara, Yemen, Zambia, Zimbabwe *If your country is not listed, please contact IBLCE at Currency 4 CERPs 8 CERPs 16 CERPs 24 CERPs Over 24 CERPs Professional Education Group USD $10 $20 $55 $75 $100 $40 EUR AUD $14 $27 $73 $99 $132 $53 STP Application Packet Fees updated on August 31, 2016 July 31, of 15

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