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«4301 N. Fairfax Drive ● Suite 301 ● Arlington, VA 22203-1633 ● T+1-703-525-4890 ● F+1- 703-276-0793 ● Continuing ...»

RECERTIFICATION PROGRAM

Continuing Practice Journal

4301 N. Fairfax Drive ● Suite 301 ● Arlington, VA 22203-1633 ● T+1-703-525-4890 ● F+1- 703-276-0793 ● www.aami.org/certification

Continuing Practice Journal Form

Name (Please print or type): Certification Expiration Date:

Preferred Mailing Address:

 Home

 Business

City: State: Zip: Country:

Telephone: Business ( ) E-Mail:

Home ( ) Fax ( )

Renewing Certification as a:

(Circle all that apply) CCE CBET CRES CLES

Year of Initial Certification: Reporting Activities for the three-year period of:

Instructions

1. Complete the top portion of this form. It is your responsibility to notify us if you have a change of address! Do not depend on the U.S. Post Office to do this via returned mail. Failure to receive an invoice (for any reason) does not relieve you of your responsibility. Renewal is based upon triennial period and deadlines always fall on December 31Pst of your triennial cycle. It is your responsibility to P notify us if you do not receive a renewal invoice prior to your certification expiration date.

2. Make sure you and your supervisor have signed the Signature Page.

3. Do not submit single pages or the point totals page alone.

4. Any of these journal forms may be photocopied.

5. Return the journal, invoice, and applicable fees to:

ACI, 4301 N. Fairfax Drive, Suite 301, Arlington, VA 22203-1633 For your inquiries regarding the process of your certification renewal, contact us at 703-525-4890 or send your inquiry by email to aci@aami.org Renewal by Continuing Professional Practice Activities I. Courses Educational activities directly related to the biomedical field that can positively affect you on a professional level may be listed in this category, such as: formal discussion groups, professional sessions, continuing education courses, etc… Types For Teaching For Attending a. Academic/Vocational course at a university or college* 1.5 pts/credit hr 1pt/academic hr b. Vendor course, short course, technical course*, workshop 1 pt/day 1/2 pt/day c. Correspondence course, teleconference, computer based course, in service, etc… 2 pts/course 1 pt/course d. Other relevant sessions 1/2 pt/day

–  –  –

II. Publications/Presentations (This section is for published or presented works by the certificant only relating to the biomedical field. Please see the Self Study Section for works read or studied.)

–  –  –

III. Professional Society Participation/Memberships (This section is for professional societies related to the biomedical field. Please do not include activities or assignments at your place of employment such as safety committees, etc.)

–  –  –

V. Work Experience a. Full time employment in the biomedical profession 1 point per year b. Part time employment in the biomedical profession 1/2 point per year c. Military reserve duty in the biomedical field 1/2 point per year

–  –  –

Employer _____________________________________________________________ _ Address _______________________________________________________________

Your Title __________________________Hours/week ______ Dates ______________

Employer: _____________________________________________________________ _______ Address _______________________________________________________________

Your Title __________________________Hours/week ______ Dates ______________

Employer _____________________________________________________________ _ Address _______________________________________________________________

Your Title __________________________Hours/week ______ Dates ______________

Employer _____________________________________________________________ _ Address _______________________________________________________________

Your Title __________________________Hours/week ______ Dates ______________

Employer _____________________________________________________________ _ Address _______________________________________________________________

Your Title __________________________Hours/week_______ Dates ______________

Employer _____________________________________________________________ _ Address _______________________________________________________________

Your Title __________________________Hours/week ______ Dates ______________

–  –  –

VI. Miscellaneous & Other Activities Any relevant activity which provides professional enhancement that is not otherwise covered above but directly related to the biomedical field. Claim points based on points assigned to similar activities.

Subject to Board approval.

–  –  –

Description of Activity: _________________________________________________ ________ ____________________________________________________________________________

____________________________________________________________________________

Location: ___________________________________Dates: ____________ Hours: _________ Description of Activity: _________________________________________________ ________ ____________________________________________________________________________

Location: ___________________________________Dates: ___________ Hours: __________ Description of Activity: _________________________________________________ ________ ____________________________________________________________________________

Location: ___________________________________Dates: ____________ Hours: _________ Description of Activity: _________________________________________________ ________ ____________________________________________________________________________

Location: ___________________________________Dates: ____________ Hours: _________ Description of Activity: _________________________________________________ _______ ____________________________________________________________________________

Location: __________________________________ Dates: ____________ Hours: __________

–  –  –

Please note: the review of your journal will be delayed if any of the information required is missing.

Certificant’s Section:

I certify that the information contained herein is correct to the best of my knowledge.

–  –  –

Signature of Certificant: ______________________________Date__________________

Supervisor’s Section:

I have reviewed the activities listed and the documents presented with this journal.

Supervisor’s Name: __________________________________________ Please Print Supervisor's Signature: _____________________________Date___________________

Supervisor’s Telephone: ___________________________________________________

Supervisor’s E-mail: ______________________________________________________

–  –  –

Name: _________________________________________________________________

Address: _______________________________________________________________

City: ___________________________ State: _______ Zip/Postal Code: _______

–  –  –

Payment Method ____ Check enclosed. All payments must be made in US dollars. Make checks payable to aami Charge my: ____ VISA ____ MC ____ AMEX Acct # ____________________________________

Exp. Date: _________________________________

Signature: _________________________________

*Note: This page is provided in the event that payment is being made without an invoice.





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