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www.diabetes.org/erp

Change of Information

Note: The ADA ERP Office must be notified within 30 days when there is a change.

This form is not required for changes made to the program:

  • Address
  • Phone Number
  • Fax Number

    All of the above changes can be made by the program coordinator through the ERP Portal (https://erp.diabetes.org).

    Complete the appropriate sections below to submit changes.

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    Change in Coordinator

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


       


       


       


       


     
    Question - Not Required - Date Coordinator left position:




     
    Question - Not Required - Date new Coordinator assumed duties:




       


     

    Change in Coordinator Email Address

       


       


     

    Change of Address or Phone Number

       


     

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

     

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

       


       


       


       


     

    Name Change

     

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

     

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

     

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

     

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

     

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

     
    Question - Not Required - Please choose one of the following:


     

    Site Closed

     

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

       


     
    Question - Not Required - Please choose one of the following reasons:


     

    (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.

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       Please leave this field empty
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