American Diabetes Association: ERP Change-of-Information

www.diabetes.org/erp

Change of Information

Note: The ADA ERP Office must be notified within 30 days when there is a change.
Complete the appropriate sections below to submit changes.

Question - Required - Program ID#

Change in Coordinator

(ERP must be informed within 30 days of the coordinator change)

Question - Not Required - Name of Coordinator who is leaving position:

Question - Not Required - New Coordinator (please include name, credentials and title):

Question - Not Required - New Coordinator's Email:

Question - Not Required - New Coordinator's Phone:

Question - Not Required - New Coordinator's FAX:

Question - Not Required - Date Coordinator left position:

Month

Day

Year

Question - Not Required - Date new Coordinator assumed duties:

Month

Day

Year

Question - Not Required - If there is a break in the above dates, please tell us who served as interim coordinator:

Change of Address or Phone Number

Question - Not Required - Site Name:

Question - Not Required - Old Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - New Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Old Phone #:

Question - Not Required - New Phone #:

Question - Not Required - Old Fax #:

Question - Not Required - NewFax #:

Name Change

Question - Not Required - Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Old Site Name:

Question - Not Required - New Site Name:

Question - Not Required - Old Sponsor Name:

Question - Not Required - New Sponsor Name:

Question - Not Required - Please choose one of the following: This is a name change only. There is no change in the program or the staff.
There has been a substantive change in the program. (You will be sent an Interim Status Report which will allow you to provide additional details about the program change.)

Site Closed

Question - Not Required - Site Name/Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Sponsoring Organization:

Question - Not Required - Please choose one of the following reasons: This site remains in operation but no longer meets the standard.
The site closed.

Question - Not Required - Please provide the date and/or reason for your previous answer:

(Maximum response 255 chars, approx. 5 rows of text)

Site Moves to Another Sponsor or
Changes in Sponsor Relationship

Please send a letter with information about the circumstances of the move or change. You may fax this to 703-991-9120 or mail it to:

American Diabetes Association
Education Recognition Program
1701 North Beauregard Street
Alexandria, VA 22311.

State whether the program has moved intact or if there have been substantive changes in the program. If you have questions about whether your program can maintain recognition, please contact us and request a copy of the Policy on Transfer of Recognition.

By submitting this online form, you are confirming you have reviewed the above information and attest to its accuracy.

Question - Required - Name of person submitting this change:

American Diabetes Association 1701 North Beauregard Street Alexandria, VA 22311 1-800-DIABETES (800-342-2383)