APPENDIX C - Application AND Credit Summary for Certification Maintenance Option By Credit Portfolio, 2009
Introduction Appendix C provides information and tools to help you apply for Certification Maintenance by Credit Portfolio option. If you have not obtained the full How To Guide for information on how to participate in the Credit Portfolio Process, please refer to it at www.cdecb.ca or from the CDECB Office, 2878 King Street, Inglewood, Ontario. L7C 0R3. Eligibility To be eligible for certification maintenance by credit portfolio you need the following: current CDE status registration with a regulatory body in Canada as a health professional Application Process To apply for the Certification Maintenance by Credit Portfolio option, please submit the following: A completed Application and Credit Summary Form (available at the end of this Appendix) in triplicate (3). Complete and accurate information must be included on the form or your application will not be processed. It will be returned to you. The total fee. A copy of your current registration certificate/card with a regulated health profession as noted above. You must submit this information to the CDECB, postmarked no later than February 1, 2009. Applications postmarked after this date will not be accepted and will be returned, without exception. You will receive acknowledgement of receipt of the application and certification summary forms by March 15, 2009. Fees Certification Maintenance by Credit Portfolio Option ..............................$450.00 Fees may be paid by VISA, cheque or money order, payable to CDECB. You will be issued a receipt. If a duplicate receipt is requested, a fee of $10.00 will be charged. Insufficient fund cheques returned to the CDECB are subject to a $25.00 penalty. Repayment of an insufficient fund cheque and the penalty must be made by a certified cheque or money order. Your application will not be processed until all fees have been received by CDECB.
Notification of results
All Forms will be reviewed by the Audit Committee and a predetermined percentage of candidates will be selected to have their complete portfolio submitted for audit. Those to be audited will be notified in writing. Complete instructions about the Audit Process will be provided at that time. The CDECB audit committee will review the selected portfolios to ensure compliance with the Credit Portfolio Process. All candidates for Certification Maintenance by Credit Portfolio will be notified in writing about the results of their application to maintain CDE status at the same time the examination candidates are notified [6-8 weeks after the exam date which is at the end of May] As a CDE, you can then continue to use the designation CDE after your name. The name on the certificate will be printed exactly as your name appears on the application form. There will be a $25.00 charge for issuing a certificate in a name other than the name you submitted on the application form. Duplicate copies of the certificate will cost $25.00. If you are unsuccessful, you will be notified in writing. As a result, you will no longer be able to use the Certified Diabetes Educator credential. To regain your status you will be required to apply to write the exam by February 1 of the following calendar year. Certification maintenance by credit portfolio will not be an option as you will not have "current CDE" status. Appeals The results of the audit cannot be appealed. Appeals can only be made based on irregularities in the certification maintenance process. If you wish to appeal you must do so within 30 calendar days of notification of certification maintenance results. You must send a letter detailing the nature of the appeal and an appeal fee of $75.00 to the CDECB. The fee will be refunded if the appeal is successful. The CDECB will acknowledge receipt of the appeal notice within 15 calendar days of its receipt and will forward a complete description of the appeal process with the acknowledgement letter. Certification Maintenance After each five-year period, you will again have the option to apply to rewrite the exam or complete the credit portfolio process prior to the expiration date on your certificate. CDECB recommends you continue to document all learning activities so that you will achieve the required 250 credits over the next five years if you choose the portfolio option when it is time to re-certify. If your certification expires prior to applying for either option, you must again meet all eligibility requirements for Initial Certification.
Revocation of Certification Certification will be revoked for any of the following: Falsification of application information Revocation, suspension or other disciplinary action by the individual's professional regulatory body Proven unethical practice of diabetes education What to submit with your application for Certification by Credit Portfolio? Submit ONLY the following materials to complete your application. It must be post marked by Feb 1, 2009: 1. CDECB Credit Portfolio Application and Credit Summary Form in triplicate (3 copies)- see next page 2. A copy of your current registration with your professional regulatory body 3. Payment of $ 450.00 Credit Card information is completed on the Application Form send a personal cheque or certified cheque You do not need to send your complete portfolio or any of the activity forms. Only candidates who are audited will need to send these forms.
CDECB Credit Portfolio Application and Credit Summary Form
PLEASE PRINT CLEARLY
CDECB reserves the right not to process applications where the following information is not provided or is not legible PART A Personal Information PLEASE ENTER YOUR NAME AS YOU WISH IT TO APPEAR ON YOUR CERTIFICATE
First Name __________________ Initial ________ Surname _______________________ Previous Name _____________________________________________________________ Address ___________________________________________________________________ City _________________________ Province ______________Postal Code____________ Phone Home: ________________________Work: ________________________
INCLUDE AREA CODE INCLUDE AREA CODE
FAX: ________________________ Email:_______________________________________
INCLUDE AREA CODE PRINT CLEARLY
Professional Status CHECK ONE
Pharmacist Physician Physiotherapist Registered Dietitian Registered Nurse Registered Psychologist Registered Social Worker Other __________________
Regulatory Body __________________________________________________________
YOU MUST INCLUDE A PHOTOCOPY OF PROOF OF CURRENT REGISTRATION
Number _____________________
Diabetes Educator Certification Status
Initial Certification Year _______ Last Year Certified _________ Any Previous Certificate # ________________ CFTNO ___________________________
LOWER LEFT CORNER OF YOUR CERTIFICATE
Diabetes Education Work Setting CHECK ALL THAT APPLY
Hospital Inpatients Hospital Outpatient Clinic Community-based Clinic Community Pharmacy Pharmaceutical Company Independent Practice Other _______________________
How long have your worked in diabetes education?
CHECK ONE
6-10 years 11-15 years 16-20 years > 20 years
The Application/Credit Summary Form is a two page document, complete both Part A and Part B
PART B Name ________________________________________________ CFTNO ___________________ ACTIVITY CATEGORY 1.0 Practice Review/Self Assessment 2.0 Organized Learning 3.0 Personally Designed Learning 4.0 Educational/Developmental/ Teaching 5.0 Publications/Quality Improvement/Research 6.0 Professional Leadership 7.0 Special Credits
MUST INCLUDE DOCUMENTATION OF PROOF FOR CREDITS CLAIMED a. Pilot Project in 2004 – claim 20% of total credits required (40 credits in 2009) b. DES Best Practices Session CDA Professional Conference 2007(5 credits) c. CDECB Competency Session CDA Professional Conference 2007(5 credits)
CREDITS IN YOUR PORTFOLIO
COMMENTS FOR OFFICE USE ONLY
TOTAL CREDITS SUBMITTED
REMEMBER:
No more than 50% of your total credits may come from any one of the six major activity categories You are encouraged to submit more than the required number of credits in case some are not allowed
I CONFIRM THIS APPLICATION/SUMMARY FORM IS ACCURATE AND CORRECT
___________________________________________________
SIGNATURE
________________________
DATE
Checklist of required documentation to be submitted before February 1st:
Completed Application and Credit Summary Form Copy of current professional registration Documentation for Special Credits, see #7 above Certification Maintenance Fee - $450.00 o Cheque or money order payable to CDECB (NSF charge $25.00) or credit card
VISA CARD PAYMENT OPTION: Card Number: _______________________ Expiry Date: ________________________ Cardholder’s Name: ___________________________________ Signature:___________________________
The Application/Credit Summary Form is a two page document, complete both Part A and Part B