1 Start 2 Complete Section 1: Project Metadata Board ID Number * 6-7 digit ID required for credit reporting. This is NOT your NPI. Date of Submission * MM/DD/YYYY Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Primary Investigator (PI) Name * First Name, Last Name, Degree PI Email Address * Title of the QI Project * Section 2: Clinical Impact & Scope Target Medical Board(s) * American Board of Internal Medicine American Board of Pediatrics American Board of Surgery List the number of team members who meaningfully participated in this QI project * Medical Doctor (MD/DO) Physician Assistant (PA) Residents Other... List the number of team members who meaningfully participated in this QI project Other... MDs * Please list the exact number of Physicians who meaningfully participated in this QI project PAs Please list the amount of Physician Assistants who meaningfully participated in this QI project Residents Please list the # of Residents who meaningfully participated in this QI project Institute of Medicine (IOM) Dimensions Impacted * Which of the six Institute of Medicine (IOM) dimensions were impacted by this study? (Check all that apply) Safety Effectiveness Timeliness Equity Efficiency Patient-centeredness ACGME Core Competencies Impacted * Which of the following ACGME Core Competencies were impacted by this study? (It is assumed that all QI projects address Practice Based Learning and Systems Based Practice. Please check all others that apply) Medical Knowledge Professionalism Patient Care & Procedural Skills Interprofessional Collaboration Interpersonal Communication Other... ACGME Core Competencies Impacted Other... Section 3: Participant DataAttestation of participation in MOC4/QI Project/Poster Please Note: To ensure all participants receive appropriate MOC Part 4 credit, you will need their Board ID Number (specific to their specialty board, e.g., ABIM), Date of Birth, Email Address, NPI Number, Medical Board Number, and Board ID Number. Please ensure you have these details ready before proceeding. For projects with multiple team members, select the number of participants below to reveal additional entry fields. Participant Name (Last, First, Title) * Participant Name (Last, First, Title) Must match Board records. Board ID Number * Board ID Number Required for MOC credit transmission. *May be different from your subspecialty number Medical Board * Please list your Specific Medical Board Date of Birth * Your full birthdate is required for learner validation Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 NPI Number * Please include your full NPI Number Participant Email Address * Additional Participant DetailsPlease provide the credentials for the additional meaningful participant. All fields below are required for MOC credit reporting.Participant 2Please provide the credentials for the second meaningful participant. All fields below are required for MOC credit reporting Participant 2 Name First name, Last Name, Credential Participant 2 Email Participant 2 Email Participant 2 DOB Participant 2 DOB Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Participant 2 Medical Board Participant 2 Medical Board Participant 2 Board ID Board ID Number: *May be different from your subspecialty number Participant 2 NPI Number Participant 2 NPI Number Participant 3Please provide the credentials for the third meaningful participant. All fields below are required for MOC credit reporting Participant 3 Name First name, Last Name, Credential Participant 3 Email Participant 3 Email Participant 3 DOB Participant 3 DOB Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Participant 3 Medical Board Participant 3 Medical Board Participant 3 Board ID Board ID Number: *May be different from your subspecialty number Participant 3 NPI Number Participant 3 NPI Number Participant 4Please provide the credentials for the fourth meaningful participant. All fields below are required for MOC credit reporting Participant 4 Name First name, Last Name, Credential Participant 4 Email Participant 4 Email Participant 4 DOB Participant 4 DOB Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Participant 4 Medical Board Participant 4 Medical Board Participant 4 Board ID Board ID Number: *May be different from your subspecialty number Participant 4 NPI Number Participant 4 NPI Number Participant 5Please provide the credentials for the fifth meaningful participant. All fields below are required for MOC credit reporting Participant 5 Name First name, Last Name, Credential Participant 5 Email Participant 5 Email Participant 5 DOB Participant 5 DOB Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20242025202620272028 Participant 5 Medical Board Participant 5 Medical Board Participant 5 Board ID Board ID Number: *May be different from your subspecialty number Participant 5 NPI Number Participant 5 NPI Number Leave this field blank
