Long-Term Provider Application Packet For education providers seeking the privilege of recognising their own educational activities with IBLCE Continuing Education Recognition Points (CERPs) As an International Organisation, IBLCE uses British English in its publications.
Table of Contents What is IBLCE?... 3 Contact Information... 3 Introduction... 3 Long Term Provider Payment Information... 3 Long Term Provider Application Form... 4 Program Content Form... 7 Independent Study Module Review Form for Long-Term Providers... 8 Speaker Disclosure & Conflict of Interest Declaration Form... 9 LTP Annual Report Form...10 LTP Payment Form..11 LTP Application Packet Page 2 of 11
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 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: cerps@iblce.org Europe, the Middle East (except Israel) and the countries of North Africa: recert@iblceeurope.org Asia Pacific and African countries (not served by the European office): admin@iblce.edu.au Introduction Individuals, independent educators, hospitals, academic institutions and professional associations are among the types of organisations that seek Long-Term Provider (LTP) status. LTPs are given the authority on behalf of IBLCE to recognise their own educational activities with CERPs. This authority comes with specific requirements and restrictions to which it is the expectation that Long-Term Providers will adhere. This application packet contains the various forms that educators will need to apply for LTP status. Long Term Provider Payment Information Fee Schedules: The LTP application fee schedule can be found on page 11. This schedule shows the initial and annual fees that need to be paid in addition to the annual fee for the number of programs provided. Payment Form: To obtain a payment form, please contact the IBLCE regional office that serves the country where you, the LTP Provider, are located. The regional office contact information is listed above. Please Note: The LTP Application Form and the LTP Payment Form must be sent together. Applications may be submitted by mail or fax; please do not send both ways. LTP Application Packet Page 3 of 11
Long Term Provider Application Form Name of Provider: Mailing Address: City: State/Province Postal Code: Country: Language of Program: Provider Website: Provider Phone: Name of Designated Contact Person: Contact Phone: Contact Email: IBCLC who oversees program content development Are you applying for LTP status for the first time? Yes No If yes, please provide the following information about three of your programs that have been previously recognised by IBLCE for at least a total of 20 CERPs. Program Name Date of CERPs Recognition Number & Type of CERPs Delivery Type (e.g. in-person, web-based, ISM) Have you ever had a LTP status in the past? Yes No Have you ever been denied LTP status? If yes, please explain why LTP status was denied: Yes No Please read the following LTP Terms and Conditions, then sign and date below. Please Note: Your original signature is required. Typed signatures are not acceptable. Terms and Conditions: During the effective dates of the Agreement to Confer IBLCE Long Term Provider Status, the Provider is permitted to recognise their own educational activities with IBLCE Continuing Education Recognition Points (CERPs) under the following conditions and requirements. 1. LTPs are given the privilege to recognise their own educational activities with IBLCE CERPs. a. LTPs cannot recognise educational activities offered by other individuals or organisations with CERPs. b. Each provider must apply to IBLCE for status as an LTP, regardless of whether they are independent of or an affiliate of an international, national or regional professional association or organisation. 2. Complete the LTP application and submit to IBLCE with the applicable fee. a. In addition, LTPs must pay an annual fee which is based on the number of CERP recognised educational activities offered each year by the provider. 3. Abide by the IBLCE Minimising Commercial Influence on Education Policy. 4. LTPs may not be a company or commercial interest as defined by IBLCE in the Minimising Commercial Influence on Education Policy. LTP Application Packet Page 4 of 11
5. The individual who oversees the content development of the educational activities offered by the LTP must be a currently certified IBCLC in good standing. 6. Prior to applying for LTP status, the educational provider must have planned, implemented and evaluated at least 3 educational activities that together were recognised by IBLCE for at least 20 CERPs. a. These 3 educational activities cannot be 3 sessions of the same educational activity and b. The 3 educational activities must have been submitted to IBLCE and recognised with CERPs within the 3 years immediately prior to applying for Long Term Provider status. 7. If previously denied LTP status, the education provider must specify the reasons for denial and the steps taken to resolve the concerns. Having a previous denial does not preclude application and/or approval; however, it is strongly advised that the provider contact the IBLCE office that serves their country before submitting their application. 8. All educational activities must be intended as professional education for IBCLCs. 9. For the benefit of IBCLCs, providers are required to distribute certificates of completion that show the number of CERPs assigned to the educational activity. 10. The LTP is responsible for distributing to and requiring all program speakers to complete a Speaker Disclosure and Conflict of Interest Form and declare any affiliation or conflict of interest (COI) that might impair the objectivity of the information they, the speakers, present. All such affiliation or conflict of interest must be brought to the attention of the participants as outlined in the Minimising Commercial Influence on Education Policy. 11. The LTP must comply with all reporting requirements established by IBLCE and must cooperate with any audits conducted by IBLCE within the given timeframe. 12. Without the express written consent of IBLCE, the LTP may not use the IBLCE logo on any of their publications regardless of the format and manner of the publication. 13. The LTP must retain all program documentation for at least 6 years following the last date the educational activity was offered. 14. LTPs 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 LTP status may be imposed. I/We understand, acknowledge and agree that I/We are required to abide by the above terms and conditions throughout the 3-year period of Long Term Provider status and that, upon approval of my/our application, I/we will be required to sign, date and return to IBLCE an Agreement to Confer IBLCE Long Term Provider Status. Signature: Date: Printed Name: Position/Title: LTP Application Packet Page 5 of 11
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: 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 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? LTP Application Packet Page 6 of 11
Program Content Form Please complete and retain this form. For programs that are selected for audit, IBLCE will require that this form be submitted. Name of Program: Date(s) of Program: Please provide information regarding each session of a program and include breaks if multiple sessions are offered. Session Title Start Time Speaker Number & Content Abstract IBLCE Detailed Type of CERPs End Time Length **To ensure proper recognition of CERPs, be as specific as possible Content Outline Discipline(s) Covered [For Office Use Only] Delivery Type (e.g. in-person, web-based, ISM) Page 7 of 11
Independent Study Module Review Form for Long-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? Every year of the 3-year ISM approval period, the LTP is required to submit to IBLCE a typed list of the individuals who completed the ISM. In addition, each ISM should be listed on the annual report as one (1) of the LTP s educational activities. 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. LTP Application Packet Page 8 of 11
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 LTP Application Packet Page 9 of 11
LTP Annual Report Form Name of Provider: Mailing Address: City: State/Province Postal Code: Country: Provider Website: Provider Phone: Name of Designated Contact Person: Contact Phone: Contact Email: IBCLC who oversees program content development Has any of the above information changed since your application or last report? Yes No Indicate the 12 months of your reporting period: Start Date End Date How many programs did you provide during this reporting period? 1-3 4-10 11-20 21-30 31 or more On separate sheet(s) and using the following format, please list the programs that you provided over the above reporting period. Your list must be typed in a table or spreadsheet format and submitted along with this completed report form, a completed payment form and payment. Please Note: All repeated programs must be listed with the dates the programs were offered. Program Name Date(s) Offered # and Type of CERPs Sample Program 2/10/20xx 12 L I/We understand, acknowledge and agree that I/We are expected to truthfully report the number of educational activities that I/we have recognised with IBLCE CERPs over the past 12 months; that my/our educational activities are subject to selection for random audit at any time; that I/we are required to abide by the IBLCE audit requirements if one or more of my/our educational activities are selected for audit and that I/We are subject to disciplinary action if I/We are found in violation of any of the LTP application, audit or reporting requirements. Signature: Date: Printed Name: Position/Title: LTP Application Packet Page 10 of 11
Long Term Provider Payment Form Name of Provider: IBLCE collects fees in 3 currencies, depending upon the IBLCE regional office which serves the country where the education provider is located. The IBLCE regional office collects fees according to the following list: IBLCE in the Americas: USD IBLCE in Asia Pacific and Africa: IBLCE in Europe and the Middle East: AUD EUR Fees for 2016 and 2017 were established in US dollars and converted to the various currencies listed above based upon a consistent and set exchange rate. Currency Initial Application Fee Annual Registration Fee LTP Fees for 2016 and 2017 Annual Annual Fee for Fee for 1-3 4-10 Programs Programs Annual Fee for 11-20 Programs Annual Fee for 21-30 Programs Annual Fee for 31 or more Programs USD $200 $200 N/A $400 $535 $800 $1075 EUR 175 175 N/A 349 467 698 938 AUD $263 $263 N/A $526 $703 $1,052 $1,414 Please note: IBLCE will invoice LTPs for the Program fees following receipt and review of the annual report. Year 1: Provider owes the Application Fee only Year 2 & 3: Provider owes the Annual Registration Fee plus the addition Program fees 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 LTP Application Form, the LTP Program Content Form and LTP 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 Credit Card: MasterCard Visa American Express Discover (American Express and Discover cards are ONLY accepted in the Americans region) Credit Card Number Total to be charged on credit card: $ Expiration Date Verification/Security No: Printed Name of Cardholder Signature of Cardholder: Date Postal Code of Cardholder: Cardholder Telephone: LTP Application Packet Page 11 of 11