Declaration Cmp Form PDF Details

Professionals seeking to revalidate their certifications understand the critical role that the Declaration Form for the Certification Maintenance Program (CMP) plays in their journey. This essential document, adhering to a structured process, marks the first step towards maintaining credentials across various categories under the CMP. Each individual certification requires a separate Declaration Form, underscored by a payment structure that includes a $75 application fee alongside additional fees for multiple certifications, and a $50 reinstatement fee for those whose certification has expired. The ASCP Board of Certification, which oversees this process, specifies a non-refundable policy for these fees while outlining a straightforward payment and submission process. Applicants need to fill out personal and professional details meticulously, using black ink, and ensure all information regarding continuing education and professional activities is accurately recorded, including any name changes with proper documentation. This form not only demands precision in its completion but enforces a stringent submission protocol, exclusively through the United States Postal Service, to avoid processing delays. The final commitment to authenticity and accuracy from the applicant through a pledge underscores the seriousness and integrity of the certification maintenance process, reflecting the ASCP's dedication to upholding high professional standards in the certification journey.

QuestionAnswer
Form NameDeclaration Cmp Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namescertification cmp ascp, s service ascp, cmp declaration, mail ascp s

Form Preview Example

DECLARATION Form for the Certification Maintenance Program (CMP)

Step 1: CMP Category

C M P Category:

NOTE: One Declaration Form must be submitted for each certification you want to revalidate.

CMP Application Fee(s)

$75 Application Fee Check/Money Order**

$15 Application Fee for each Additional Certification

Additional certification(s), must have the same expiration date or be within three months of each other. Please submit a separate Declaration Form for each certification.

$50 Reinstatement Fee

Required if your certification has expired. This fee is in addition to the $75 CMP fee.

Please allow 30 business days for processing your declaration form.

For detailed information on completing the CMP, please go to www.ascp.org/cmp

2: Payment Information

Check/Money Order (Payable to ASCP Board of Certification)

** You may also apply online with a Credit Card.

$ AMOUNT SUBMITTED* TOTAL

Please add all fees that apply. *Application fees are not refundable.

Mailing Address: Board of Certification, 3335 Eagle Way, Chicago, IL 60678-1033

CMP Declaration and application fee(s) MUST be mailed by the United States Postal Service Regular mail only. DO NOT send application(s) and fee(s) by fax, Federal Express, UPS, Express Mail, Certified or Registered Mail or any overnight courier service or any other express mail service. CMP Declaration(s) and application fee(s) using express mail service will not reach the BOC office.

Please Note: Do not send supporting documentation with your declaration. Documention is required only if you are notified that your declaration has been selected for audit.

Step 3: Personal Information (Fill out completely. Print plainly in black ink.)

Birth Date (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Customer ID (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone Number (Required)

 

 

 

 

 

 

 

 

 

 

 

 

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Last 4 digits of U.S. Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

 

 

Office

 

 

 

Cell

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle

Last Name (as it appears on your identification)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name (as it appears on your identification)

 

 

 

 

 

 

 

 

 

 

 

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden Name (if applicable)

Email Address (Required)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Country (if foreign)

My address has changed.

My name has changed (documentation enclosed*).

*Name Change: If your name has changed and you have not yet notified our office, please do so by sending a photo copy of official name change documentation (i.e., marriage license or court order). To submit a name change request online. Go to www.ascp.org/bocfeedback, select the topic Change Name/Contact Information and the subject Name Change. You will be prompted to login. Upload your document(s) if you have them in an electronic format and send them via email OR you can print a cover sheet and mail your name change document(s) to: ASCP Board of Certification, 33 W. Monroe St, Suite 1600, Chicago, IL 60603, Attn: Name Change Recertification will not be processed until name change has been completed.

4: ASCP Certification:

Required Participant

Voluntary Participant

REVISED 4/2014

1

5:Activities Description List: Activities must be related to area of specialty and safety. (Attach additional pages as needed.)

Please provide the specific area of interest/specialty for each activity, e.g. blood banking, chemistry, hematology, immunology, etc.

One (1) CMP point = One (1) Contact hour = One (1) CMLE Credit

Activities

Area of Interest/

 

Speciality (Required)

Formal continuing education courses, teleconferences, subscription or online courses where formal continuing education credits are awarded.

Course Title

Participation Date

CMP Points/ Contact Hours

Employer-offered courses, in service programs, vendor-sponsored course.

Formal College/University coursework. Courses must be lab related (biological/ chemical/medical science, management or education.) CEs should not exceed 50% of the total number of required CMP points for your category.

Area of Interest/ Speciality (Required)

College Title and Name of College/University

1.

2.

Course Title

Course Title

Participation Date

Participation Date

CMP Points/ Contact Hours

CMP Points/ Contact Hours

Total Points

2REVISED 4/2014

6:Activities Description List: Continued. (Attach additional pages as needed.)

For current CMP guidelines for point equivalency, please refer to this link: www.ascp.org/cmp

Activities

Institution/Supervisor’s Name

Competence assessment by employer. (2 points per year/Maximum 4 points total accepted in three year cycle)

ASCP ID #

Assessment Date

CMP Points

Research and Preparation for presentation of workshop or course. (You may recieve credit only for the first time a presentation is given.)

Authoring a book or book chapter, doctoral dissertation.

Course Title

Name of Book, Doctoral Dissertation

Presentation Date

Publication Date

CMP Points

CMP Points

Book Title

Editing a book.

Description of Poster/Exhibit

Presenting posters/exhibits.

Titles

Journal articles, master thesis.

Committee Name/Organization

Serving on examination committees, committees or boards related to the profession.

Names of Institution Inspected &

Accreditation Agency

Role of on-site inspector/paper reviewer for laboratory accreditation (JCAHO, CAP, etc,) or training program accreditation (NAACLS, CAAHEP) 2 pts/year.

REVISED 4/2014

Publication Date

Presentation Date

Publication Date

Dates of Service

Date

Total Points

CMP Points

CMP Points

CMP Points

CMP Points

CMP Points

3

7:Pledge of Authenticity: Please read and sign below. Any declaration received without a signature will be considered incomplete.

By submitting and signing this declaration, I acknowledge that this declaration form will be reviewed and that an audit may be conducted in accordance with the rules and policies adopted by the ASCP Board of Certification. I agree to hold harmless the members, examiners, officers, and agents of the ASCP Board of Certification from any and all actions that they may take, or refrain from taking, pursuant to such rules and policies.

I certify that all information contained in this declaration form, as well as any information that I may submit in support of this declaration form is true and correct to the best of my knowledge and belief. I authorize representatives of the ASCP Board of Certification to verify the accuracy of any information contained in, or supplied in support of, this declaration form from any person or persons having knowledge of such information. I recognize that successful completion of the Certification Maintenance Program is based on the correctness of the information contained in, and supplied in support of, this declaration form.

I further recognize that the certificate I may be granted, may be revoked at any time, and that I may be barred from participation in future ASCP certification and/or Certification Maintenance Programs, if it is established that the information contained in, or supplied in support of, this declaration form is inaccurate in any material respect or if it determined that I have misrepresented or misused any certification I may have or be granted.

I understand that the certificate of certification is time-limited for three years and that it must be renewed every three years for my certification to remain valid. (This statement does not apply to voluntary CMP participants who are not required to complete the CMP to maintain certification.)

I understand and agree that I will not use the ASCP certification designation or CM (in superscript) after my name if I do not maintain a valid certification.

Signature

Date

Please complete the Declaration Form, enclose the required fee by check or money order made payable to the ASCP Board of Certification and mail to:

ASCP Board of Certification

3335 Eagle Way

Chicago, IL 60678-1033

FAXED DECLARATION FORMS WILL NOT BE ACCEPTED.

If your Declaration Form is chosen for audit, you will be notified by mail. Do not use the above Eagle Way address for Federal Express, Express Mail, certified, registered or any overnight courier service.

4REVISED 4/2014

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