Continuing Education Contact Hours

Thank you for visiting this page to complete the CECH Attestation Form. This form should be completed if your CECH certificate is missing hours you feel were earned. A witness is required to sign the form; a witness is considered someone who can attest that you participated in the lectures for the hours being requested.

Upon submission of the form, the MPC will review the request. A CECH certificate for the missing hours will be sent by email for those whose requests are approved. This process can take 5-7 business days.

Note that this form is not for learners who knowingly did not view lectures for a particular session. The meeting’s records will be reviewed to determine that you attended the session for which you are requesting hours.

CECH Attestation Form

"*" indicates required fields

CECH Attestation Form*

I agree that the following are true

WHEREAS, The undersigned, has registered for and attended the indicated Continuing Education Conference (hereinafter “Conference”); and
WHEREAS, The Conference is required, by the Council on Podiatric Medical Education (CPME), to obtain a verification of each attendee’s participation in, and/or presence at, all lectures, as well as clinics, which make up the curriculum of the Conference; and
WHEREAS, The attendee’s presence and participation are the basis through which the Conference grants Continuing Education Contact hours to the Attendee; and
WHEREAS, The Continuing Education contact hours granted through the Conference may be necessary to the support the Attendee’s licensure in the state in which the Attendee holds a license to practice podiatric medicine; and
WHEREAS, Verification of attendance and participation is offered at the Conference through an attendance verification of the Attendee’s name badge or electronic scanning record; and
WHEREAS, The undersigned did not successfully obtain or submit an electronic attendance verification to confirm the Attendee's participation in those lectures or clinics listed below; and
WHEREAS, The Attendee has requested that the Conference verify the Attendee’s attendance at and participation in the lectures and/or clinics listed below, by issuing Continuing Education contact hours for the lectures and/or clinics listed below; and
WHEREAS, The Conference is willing to verify said attendance based upon the Affidavit signed below:

Affidavit
And Now, on the date of this submission, the undersigned swears and affirms that the undersigned registered for, attended in person and participated in the lectures and/or clinics offered at the Conference first named above, which lectures and/or clinics as specified in the form below;
AND FURTHER, the undersigned made a good faith effort to obtain the appropriate attendance verification offered by the Conference for the said listed lectures and/or clinics, but was unable to obtain the said electronic scan due to the following circumstance, as entered in the form below;
AND FURTHER, the undersigned herby requests that the Conference issue and grant the undersigned the appropriate Continuing Education Contact Hours which attach to the lectures and/or clinics listed in this Affidavit form below;
AND FURTHER, should the Council on Podiatric Medical Education request any additional proof or verification of attendance or participation that the undersigned shall promptly comply with said request.
Sworn to and attested on the day and date first recited below:

Name*

First Last

Email*

Attendance verification session in question*

Session(s)

Provide explanation of request for missing CECH*

Signature*

Witness Name*

Please provide the name of another attendee whose attendance is verified and can attest to your attendance.

First Last

Witness Email*