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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.

Copyright © 2016-2017, International Board of Lactation Consultant Examiners. All rights reserved.

STP Application Packet

July 31, 2016

2 of 15 www.iblce.org

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 ................................................. 10

STP Application Checklist ................................................................................................... 11

STP Payment Form …………………………………………………………………………………12

Fee Schedule…………………………..…………………………………………………………….13



July 31, 2016

3 of 15 www.iblce.org

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) 10301 Democracy Lane, Suite 400 Fairfax, Virginia 22030 -2545 USA Phone: 703-560-7330 Fax: 703-560-7332 www.iblce.org

IBLCE has offices in Austria, Australia and the United States. To reach the IBLCE office that serves your country, use the following email addresses.

North America, South America and Israel: [email protected]

Europe, the Middle East (except Israel) and the countries of North Africa: recert@iblce- europe.org

Asia Pacific and African countries (not served by the European office): [email protected]

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, 2016

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Short-Term Provider Application Form Name of Provider: ______________________________________________________________ Provider Website: _______________________________________________________________

Provider Phone: ________________________________________________________________ Name of Designated Contact Person: Contact Phone: Contact Email: 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 including 4 CERPs up to and including 8 CERPs up to and including 16 CERPs

up to and including 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: ______________________________



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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


manner of the publication or material.

The STP must retain all program documentation, including 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:

Copyright © 2016-2017, International Board of Lactation Consultant Examiners. All rights reserved. 6 of 15 www.iblce.org

http://www.iblce.org/

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

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:

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?



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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, including 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

Content Outline Discipline(s) Covered [For Office Use Only]

Delivery Type (e.g. in-

person, web-based, ISM)

Type of CERPs

**To ensure proper recognition of CERPs, be as specific as possible

End Time

Length


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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 Email: ________________________________________

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




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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.




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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 http://iblce.org/about-iblce/worldwide-offices/

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.


http://iblce.org/about-iblce/worldwide-offices/


STP Application Packet Last updated July 2016

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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 60 60

3 choices of 60 minute concurrent breakout

sessions

60 180

45 minute closing plenary session 45 45

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:


Copyright © 2016-2017, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org July 31, 2016

13 of 15 STP Application Packet Fees updated on August 31, 2016

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 [email protected].

Currency Up to and

including

4 CERPs

Up to and

including

8 CERPs

Up to and

including

16 CERPs

Up to and

including

24 CERPs

Over 24

CERPs

Professional

Education

Group

USD $55 $90 $140 $200 $265 $185

EUR €48 €79 €122 €174 €231 €161

AUD $73 $119 $185 $264 $350 $244


mailto:[email protected]



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


Currency Up to and

including

4 CERPs

Up to and

including

8 CERPs

Up to and

including

16 CERPs

Up to and

including

24 CERPs

Over 24

CERPs

Professional

Education

Group

USD $35 $55 $90 $110 $175 $90

EUR €31 €48 €79 €96 €153 €79

AUD $47 $73 $119 $146 $231 $119





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


Currency Up to and

including

4 CERPs

Up to and

including

8 CERPs

Up to and

including

16 CERPs

Up to and

including

24 CERPs

Over 24

CERPs

Professional

Education

Group

USD $10 $20 $55 $75 $100 $40

EUR €9 €18 €48 €66 €87 €35

AUD $14 $27 $73 $99 $132 $53



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