Application for Certificate of Completion
The CPPPH Certificate of Completion is described with all details and requirements in the Project Description HERE.
To receive a certificate from CPPPH documenting completion of all portions of the activity for identifying evaluators, you must request the certificate in advance of the workshop, submit the completed application form and all specified attachments by the October 30th deadline, pay an additional fee of $35, and complete the pre-/post tests administered at the workshop. After the December workshop, CPPPH will make available, on request, the list of those with a certificate of completion.
Complete and submit the form below, and provide us with the three items listed below, and submit the payment of $35 (NOTE: this is a non-refundable amount). You can send these items as an attachment to an email to email@example.com, or by fax to CPPPH at 800-381-2383, or by mail to CPPPH Inc. at 575 Market Street, Suite 2125, San Francisco, CA 94105. Identify them with your name, as attachments to your application for the CPPPH Certificate of Completion. Remember, the application for the certificate of completion must be received by October 30.
- A current, dated copy of your CV
- A redacted copy of an evaluation report you have prepared and submitted to a medical staff or other entity responsible for maintaining quality of care and patient safety. The report, as you have redacted it to eliminate identifying information, will be used with other reports during the faculty-led small group discussion at the workshop to show the elements of the report.
- A page with the full name, title, and full contact information for the person** you have asked to submit a letter of reference for you from an organization to which you submitted an evaluation report. The person chosen should be the chair of the committee (e.g., wellbeing committee, medical executive committee), director of medical staff services, department head, or other person who received the report and who is in a position responsible for maintaining quality of care and patient safety in that medical setting. We will contact the person and ask for a letter that specifies the date of the report received from you and comments on how it was viewed and used in their processes.
**We will request a letter from that person. Please be sure you have secured that person’s agreement to submit a letter for you.**
- To submit payment for the certification, include it in your registration for the workshop. If you have already registered for the workshop, return to your registration record (LA Registration or Oakland Registration), and modify your registration to add the fee.
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We will confirm receipt of your application for the Certificate of Completion by email.
Applications for the CPPPH Certificate of Completion cannot be accepted after October 1, 2015.
There is no deadline for registration for workshops, but attendance is limited by space and early registration is recommended.
For questions or other information,
contact CPPPH at 800-381-2383 or firstname.lastname@example.org.