Reach Out and Read Quality Improvement (QI) Project for Maintenance of Certification/CME
Registration Form
Thank you for your interest! This Registration Form includes:
 Page 1: QI Participant Roles and Responsibilities (Please retain for reference.)
 Page 2: Reach Out and Read Practice Registration Form and Payment Instructions (clinic/practice information)
 Page 3: Participating Provider Registration Form and Payment Instructions (for MOC/MC-FP/CME-qualifying providers )
Please complete pages 2-3 and submit via
 Scan to: QI@reachoutandread.org
 OR mail to: Reach Out and Read, 56 Roland Street, Suite 100-D, Boston, MA 02129-1243, Attn: QI Administrator
For more information about the Reach Out and Read QI Project, please click here.
QI for MOC/MC-FP/CME: Participant and Practice Roles and Responsibilities
Each MOC/MC-FP/CME-qualifying participant in the Reach Out and Read QI Project commits to the following:
 Prerequisites: Completing the Reach Out and Read Core Training course; reading the Quality Improvement Project Overview and Quality Improvement
Methods documents.
 Formation of an QI Project Team that includes all providers and staff participating in this Project; identifying a Project Chair to lead meetings and
facilitate communication and a Project Administrator to coordinate meetings and assure timely, accurate data entry into the myROR.org website.
 Active participation in mandatory conference calls/webinars and on-site QI Committee/Project Team meetings; identification of one or more Reach Out
and Read Program process changes; data collection from book inventory, well child visits, and QI Project parent surveys; data entry and documentation
required for MOC/MC-FP/CME. Past participants report that the project requires 3-5 hours per month.
Each participating Reach Out and Read program site documents that has the following prerequisites:
 100% of books needed for the four-month data collection period
 Medical and administrative leadership support for the QI Project
A QI Coach assigned to each participating clinic/practice moderates monthly webinars, discusses QI Project results with participants, answers questions, and
advises on QI Project and Reach Out and Read program administration. To receive applicable credits, each eligible participant completes a Project evaluation,
the appropriate attestation documentation, and an optional CME test at the conclusion of the QI Project.
Resident Participation in the QI Project
Pediatric residents are welcome to participate in the QI Project under the supervision of a MOC-qualifying physician; however, their participation is not
monitored or recorded by Reach Out and Read.
Family Medicine residents may participate to receive MC-FP credit in one of three ways:
1. Registering with ROR as a Participating Provider for MC-FP credit (with appropriate fees) and submitting evaluation and attestation to Reach Out and
Read at conclusion of the Project.
2. Submitting attestation for Self-directed Quality Improvement Effort directly to ABFM at the end of the Project.
3. Documenting participation in the QI Project via the ABFM’s Resident Portfolio System.
Page 1 of 3
ROR Site ID# __________
Reach Out and Read Program Registration Form
Please fill out this form completely and accurately.
Clinic/Practice Name: ___________________________________________________________________________________________________________
Street Address: ____________________________________
City: ______________________
State: ______
Zip: _________________
Certification of Support:
The signatures below certify our committed support for the Reach Out and Read Quality Improvement Project at our facility:
______________________________________________________________________________________________________________________
Reach Out and Read Program Medical Director/Clinic Medical Director
Date
______________________________________________________________________________________________________________________
Reach Out and Read Program Coordinator/Clinic Administrator
Date
Program Registration Fee Payment:
The QI Project requires payment of $500, via PayPal only, for each Reach Out and Read program site.
To pay via PayPal:
1. Go to https://www.reachoutandread.org/QI/payment/Default.asp.
2. Complete the required fields, indicating “Program” Application Type, and click on
.
3. Log in at
OR
3. Complete the required fields under
and click on
to enter credit card data and submit payment.
Submit this Registration Form:
Complete and submit pages 2-3 of this registration form via:
Scan to QI@reachoutandread.org
OR
Mail to Reach Out and Read, 56 Roland Street, Suite 100-D, Boston, MA 02129-1243, Attn: QI Administrator
Questions? Email QI@reachoutandread.org or call 617-455-0630.
Page 2 of 3
ROR Site ID#__________
Participating Provider Registration Form
Please submit one page per MOC/MC-FP/CME-qualifying provider, printing additional sheets as needed.
*Please provide up-to-date email address and telephone number where we can reach you (not your clinic receptionist) directly. The QI Team is committed to supporting you
in achieving Maintenance of Certification; however, we are able to do so only if you provide complete and accurate contact information.
1
Your ROR Program Administrator may be able to provide you with your myROR Contact ID#.
Last Name: ___________________________
*Phone: ____________________
First Name: ___________________________
myROR Contact ID# (if known) 1: _______________
*Email Address: ____________________________________________ Certifying Board (ABP, ABFM): ____________
MOC/MC-FP Expiration Date: ____________
Check here if you will serve as the QI Project Chair: ______
I understand the roles and responsibilities of participating in the Reach Out and Read QI Project for Maintenance of Certification/Continuing Medical
Education credit and hereby certify that I will fulfill the roles and responsibilities required for Project credits.
______________________________________________________________________________________________________________________
(Participant Signature)
Date
Participating Provider Payment: The QI Project requires payment of $250, payable via PayPal only, for each MOC/MC-FP/CME-qualifying provider.
To pay via PayPal:
1. Go to https://www.reachoutandread.org/QI/payment/Default.asp.
2. Complete the required fields, indicating “Provider” Application Type, and click on
.
3. Log in at
OR
3. Complete the required fields under
and click on
to enter credit card data and submit payment.
Submit this Registration Form:
Complete and submit pages 2-3 of this registration form via:
Scan to QI@reachoutandread.org
OR
Mail to Reach Out and Read, 56 Roland Street, Suite 100-D, Boston, MA 02129-1243, Attn: QI Administrator
Questions? Email QI@reachoutandread.org or call 617-455-0630.
Page 3 of 3