This attestation must be completed by the physician or PA seeking MOC Part IV credit from one or more of the ABMS Member Boards participating in this program. Please submit the poster attestation and a copy of the poster in a PowerPoint or PDF format by November 14th to receive credit in the current year. Credit can only be rewarded for those posters that reflect clinical quality improvement effort done at least partially if not completely within the previous 12 months (this does not include clinical research). Physicians and PA are not eligible to receive credit for a poster that reflects on effort that has been previously submitted.Posters are required to include adequate and appropriate:Aim Statement/SMART Goal (Specific, Measurable, Achievable, Relevant, and Time-bound)Measures that are aligned to determine if change occurs and relate directly to the Aim Statement/SMART GoalInterventions that have been aligned to impact the measures and were implemented into practice POSTER TITLE * FIRST NAME (GIVEN NAME) * AS LISTED WITH YOUR CERTIFYING BOARD LAST NAME (FAMILY NAME) * AS LISTED WITH YOUR CERTIFYING BOARD EMAIL * NPI (10-DIGITS) * FIND YOUR NPI DATE OF BIRTH * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 BOARD INFORMATION * INDICATE YOUR CERTIFYING BOARD(S) AND YOUR UNIQUE DIPLOMATE NUMBER(S) UPLOAD QI POSTER * Files must be less than 16 MB.Allowed file types: pdf ppt pptx. INDICATE THE BEGINNING AND ENDING DATE OF YOUR PARTICIPATION IN THE QI EFFORT * MM/DD/YYYY-MM/DD/YYYY HOW WERE YOU INVOLVED IN THE QI WORK DESCRIBED ON THE POSTER? * PLEASE BE SURE TO PROVIDE COMPLETE, THOUGHTFUL RESPONSES WHAT DID YOU LEARN AS PART OF PARTICIPATING IN THIS QI EFFORT? * PLEASE BE SURE TO PROVIDE COMPLETE, THOUGHTFUL RESPONSES EXPLAIN HOW YOU PLAN TO SUSTAIN THE CHANGES YOU MADE TO YOUR PRACTICE AS A RESULT OF THIS QI EFFORT? * PLEASE BE SURE TO PROVIDE COMPLETE, THOUGHTFUL RESPONSES I ATTEST I PARTICIPATED IN THE QI WORK DESCRIBED IN THE POSTER. * Yes No Leave this field blank