Celiac Disease Unit Recognition Program Application

Society for the Study of Celiac Disease

Celiac Disease Unit Recognition Program Application

The application must be reviewed and signed by the medical director of the celiac disease unit. If applying for more than one unit, please provide this information for each unit on a duplicate form.

Please check one(Required)

New Application

Reinstatement

Expiration date

CELIAC UNITY TITLE AND CONTACT INFORMATION

(Important! Please list your unit/group name exactly as you wish it to appear on your recognition certificate, if awarded.)

Full Name(Required)

As the medical director of this unit, I hereby attest to the accuracy of all information submitted via this application with my signature.

Medical Director Signature(Required)

Date(Required)

Name of Unit(Required)

Contact Name(Required)

Contact Role(Required)

Member of SSCD(Required)

Address(Required)

Phone(Required)

Unit Website

Institutional affiliation of your celiac disease office/unit(s), if applicable

Total number of celiac disease units for which you are seeking recognition(Required)

For the purposes of the CDURP Program, units at separate physical addresses are considered separate units, regardless of institutional affiliation or ownership. Each unit must pay a separate annual recognition fee. Please complete an application for each individual unit seeking recognition and note the additional unit names below or on a separate page.

UNIT MEMBERS

At least 50% of the entire team working in the unit must be SSCD members, defined as any physician, nurse, nurse practitioner, dietitian or medical personnel, regardless of specialty.

Personnel(Required)

Name

SSCD Member?

Degree

Role in Unit

Email Address

RESEARCH AND QUALITY IMPROVEMENT

Please indicate any/top research or QI activities which your unit has undertaken in the last five years. Describe the activity, its outcomes (to date) and its impact on your celiac disease practice. Use additional sheets to describe the program/activity, as needed.

Any/top research or QI activities(Required)

EDUCATION

Attendance/involvement by unit members in celiac-associated meetings (DDW®, Canadian Association of Gastroenterology, ICDS, NASPGHAN, SSCD Webinars, ACG, or other celiac disease-dedicated meetings or sessions) please list no more than 5 activities. For large conferences , please list the conference name itself and do not list individual sessions.

Activities(Required)

Activity Name and Date

Participants attended

LEADERSHIP AND ADVOCACY

Please list any SSCD activities members have been involved in.

PAYMENT

Select Recognition(Required)

Phone

This field is for validation purposes and should be left unchanged.