Attestation – HAFP Sponsored ABFM PI Project

This form should be completed by American Board of Family Medicine (ABFM)-certified physicians who seek Family Medicine Certification credit for completing an approved Performance Improvement (PI) activity.

Physician and Activity Information

First Name *

Last Name *

Email *

ABFM Board ID *

Activity Name *

Start Date of Participation *

End Date of Participation *

Physician Attestation

I attest to the following statements: *

I was engaged in planning and executing the project.
I was involved in the changes implemented during the project.
I regularly reviewed data in keeping with the project’s measurement plan.
I participated in any team meetings for the project.

Describe your individual involvement in the project, including lessons learned: *

By submitting this physician for Family Medicine Certification credit, the organization is indicating that the physician has successfully completed their participation within the named activity, meeting all of the requirements for meaningful participation.

Please note that applicable certification fees must be current for credit to be posted to the Diplomate’s record.