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 ................................................................................................................................. 6 Independent Study Module Review Form for Long-Term Providers ...................................................... 7 Speaker Disclosure & Conflict of Interest Declaration Form ................................................................... 8 LTP Annual Report Form .............................................................................................................................. 9 LTP Application Packet Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 2 of 10 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)
6402 Arlington Blvd, Suite 350
Falls Church, Virginia 22042
USA
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 or Israel: cerps@iblce.org
Europe, the Middle East (except Israel) or the countries of North Africa: recert@iblceeurope.org
Asia Pacific and African countries (not served by the European office): cerps@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 12. 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: All documents—LTP Application Form and the FTP Payment Form—and payment
must be sent together. Applications may be submitted by mail or fax; please do not send both
ways.
LTP Application Packet Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 3 of 10 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
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.
2.
3.
4.
LTPs are given the privilege to recognise their own educational activities with IBLCE CERPs.
a. LTPs may not 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
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.
Abide by the IBLCE Minimising Commercial Influence on Education Policy.
LTPs may not be a company or commercial interest as defined by IBLCE in the Minimising Commercial
Influence on Education Policy.
LTP Application Packet Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 4 of 10 5.
6.
7.
8.
9.
The individual who oversees the content development of the educational activities offered by the LTP must
be a currently certified IBCLC in good standing.
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.
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.
All educational activities must be intended as professional education for IBCLCs.
For the benefit of IBCLCs, providers are required to distribute certificates of completion that show the
number of CERPs assigned to the educational activity and for participants who are not IBCLCs, the
number of instructional hours in subjects listed on the IBLCE Detailed Content Outline.
For the benefit of IBCLCs, providers are required to distribute certificates of completion that show the
number of IBLCE CERPs recognised.
a. For participants who are not IBCLCs, the number of instructional hours in subjects listed on the
IBLCE Detailed Content Outline must be shown on the certificate of completion.
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 Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 5 of 10 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
End Time
Length
Speaker
Number
& Type
of
CERPs
Content Abstract
**To ensure proper recognition of CERPs, be as
specific as possible
IBLCE Detailed
Content Outline
Discipline(s) Covered
[For Office Use Only]
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
Please report any significant problems here:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 7 of 10 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 Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 8 of 10 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
Sample Program
Date(s)
Offered
2/10/20xx
# and Type of
CERPs
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: ______________________________________________________________________
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:
IBLCE in Asia Pacific and Africa:
IBLCE in Europe and the Middle East:
USD
AUD
EUR
Fees for 2015 were established in US dollars and converted to the various currencies listed
above based upon a consistent and set exchange rate.
LTP Fees for 2015
Currency
Initial
Application
Fee
Annual
Registration
Fee
Annual
Fee for
1-3
Programs
Annual
Fee for
4-10
Programs
Annual
Fee for
11-20
Programs
Annual
Fee for
21-30
Programs
Annual
Fee
for
31 or
more
Programs
USD
EUR
AUD
$200
€178
$253
$200
€178
$253
N/A
N/A
N/A
$400
€357
$506
$535
€477
$677
$800
€713
$1,012
$1075
€959
$1,360
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. I/We must send the signed LTP
Application Form, the LTP Program Content Form and LTP Payment Form, with all required credit card information,
by fax to IBLCE. 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. In addition, I/we understand that payment must be made in
US dollars if I/we are applying in the Americas region. Therefore 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. Cheques and money orders are only accepted in the Americas region.
I/We wish to submit all required paperwork by mail and will pay using, a credit card, (cheques, or money order
are only accepted in the Americas region). I/We must print and sign the LTP Application Form and send it along with
the LTP Payment Form and payment to the IBLCE office. Furthermore, I understand and agree that, if payment is not
enclosed, the application will not be reviewed until payment is received.
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 No: ______________
Printed Name of Cardholder______________________________________________________________
Signature of Cardholder: _______________________________________________________________
Postal Code of Cardholder: ____________________Cardholder Telephone: _______________________
LTP Application Packet Copyright © 2015, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org May 2015 Page 10 of 10