8 webinars per calendar year for new staff 4 webinars per calendar year for continuing staff If you are a new Affiliate filling out a Site Survey for the first time, then all staff seeing patients must have completed 8 webinars this past calendar year. 1. Lead Staff Person Info: Name: Credential (RN, RD, BMS, MD, etc.): License #: Email: Direct Line: Best way to contact Lead Staff Person: ☐ ☐ Lead Staff Person’s Completed Webinars (Check all that apply): 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT ☐January 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD ☐February 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE ☐March 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD ☐April 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD ☐May 22, 2016 - Nutrition, Diabetes & Pregnancy Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, ☐June CDTC, CLE 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐July 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD ☐August 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, ☐September IBCLC, RLC 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG ☐October 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, ☐November LPCC, BC-DMT 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD ☐December Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived ☐Recorded Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: 2. Information for 2nd Staff Person: Name: Credential (RN, RD, BMS, MD, etc.):
8 webinars per calendar year for new staff 4 webinars per calendar year for continuing staff If you are a new Affiliate filling out a Site Survey for the first time, then all staff seeing patients must have completed 8 webinars this past calendar year. 1. Lead Staff Person Info: Name: Credential (RN, RD, BMS, MD, etc.): License #: Email: Direct Line: Best way to contact Lead Staff Person: ☐ ☐ Lead Staff Person’s Completed Webinars (Check all that apply): ☐January 27, 2016 - Exercise and the Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE, CLT ☐February 24, 2016 - Insulin Pump Therapy; Presenter: Thomas R. Moore MD ☐March 23, 2016 - Following a GDM Pregnancy; Presenter: Leona Dang-Kilduff RN, MSN, CDE ☐April 20, 2016 - Medical Management of Type 1 Diabetes during Pregnancy; Presenter: Kathleen M. Berkowitz MD ☐May 18, 2016 - The Effects of Maternal Diabetes on Fetal Development and Outcomes; Presenter: Sherrie McElvy MD ☐June 22, 2016 - Nutrition, Diabetes & Pregnancy Bariatric Surgery; Presenter: Geetha Rao MS, RD, CDE, CPT, CDTC, CLE ☐July 27, 2016 - CDAPP Sweet Success Program Update; Presenter: CDAPP Sweet Success Resource and Training Center ☐August 31, 2016 - Managing Diabetes during Pregnancy and Postpartum; Presenter: Thomas R. Moore MD ☐September 28, 2016 - Breastfeeding After a Pregnancy Complicated by Diabetes; Presenter: Gretchen Andrews BA, IBCLC, RLC ☐October 26, 2016 - Obesity and Diabetes during Pregnancy; Presenter: Daniele Feldman MD, FACOG ☐November 16, 2016 - Maternal Mental Health and Diabetes during Pregnancy; Presenter: Gabrielle Kaufman MA, LPCC, BC-DMT ☐December 14, 2016: Diagnosing Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD ☐Recorded Webinar that originally aired live in 2015 (but this staff person watched it in 2016), found in the Archived Section of the CDAPP Sweet Success website. Please list webinar title(s) and date(s) below: 2. Information for 2nd Staff Person: Name: Credential (RN, RD, BMS, MD, etc.):
CDAPPSweetSuccessAffiliateApplication.docx