CIC Prep Course Application Form | Texas Hospital Association

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No one likes it when a form has an error and all your hard work is lost. Be sure to save your work before submitting the form below just in case.

If you experience any issues with the form, please contact the THA Service Center at servicecenter@tha.org or 512/465-1057.

THA is pleased to offer this Virtual CIC Prep Course 2022 to a limited number of qualified THA Members free of charge. (Valued at over $1,000 per person.)

Due to the interest in this web-based program, the application process is highly competitive. Please take that into consideration when submitting your application.

Outside funding through the THA Foundation to offset the cost of the program for THA Members for subsequent years of the program is contingent upon future contributions and grants.

*Additional resources, exam practice textbooks, and exam costs are the responsibility of the participant. Attendees and/or their organization will be responsible for any fees associated with the application and testing for the IC® Initial Certification.

Virtual CIC Prep Course 2022 Application Form

Biographical Information:

Full Name:(Required)

Degrees:(Required)

License(Required)

Current Job Role/Title:(Required)

Start Date of Current Role:(Required)

Areas of Responsibility:(Required)

Number of Years in Infection Prevention Role:(Required)

Hospital/Organization Name:(Required)

Mailing Address:(Required)

Street Address City State ZIP Code

Daytime Phone:(Required)

Fax:

Email Address:(Required)

Enter Email Confirm Email

Are you currently a member of APIC?:(Required)

Yes

If Yes, please provide your APIC Member ID #:

Supplemental Application:

Attach Resume:(Required)

Please include a current copy of your resume or CV. Accepted Formats: Word Doc or PDF.

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Required Acknowledgement of Attendance Requirements:

One of the main benefits of this program is the knowledge and idea sharing that will accompany each learning session. Therefore, attendance by all CIC participants at every learning session is of utmost importance.

By checking this box, if accepted into the program, you are agreeing to attend all required learning sessions and are acknowledging the importance of regular attendance.

Yes, I acknowledge(Required)

Yes, I acknowledge

Please note—Attendees who do not complete each required learning session will not be granted their certification of completion until they meet all the requirements by attending each learning session.

June 7, 2022	CIC Exam Preparation, Test Scheduling, and scholarship review ID of Infectious Disease Agents
June 21, 2022	ID of Infectious Disease Agents/Surveillance and Epidemiology
July 5, 2022	Transmission based precautions
July 19, 2022	Employee/Occupational Health
August 2, 2022	Management and Communication/Education and Research
August 16, 2022	Environment of Care / Cleaning, Disinfection, Sterilization
August 30, 2022	Cleaning, Disinfection, Sterilization/Summary and Review

Required Attestation of Eligibility

Acceptance to this prep course requires your attestation that you will be eligible to sit for the CIC exam at the completion of the seven virtual sessions. Please carefully and fully review the eligibility requirements at www.cbic.org/CBIC/Candidate-Handbook/Eligibility-Requirements.htm.

The CBIC also offers an easy to use interactive “Am I Eligible?” tool at apps.cbic.org/certification-tools/eligibility-tool/.

Yes, I am eligible(Required)

By checking the box below, you attest that you will be eligible to sit for the CIC exam at the completion of this prep course.

Yes, I am eligible

Recommendation Letter:

We require a professional recommendation letter from your current supervisor who has assessed your performance during your career in Infection Prevention and Control and can attest to your ability to bring value to the THA Virtual CIC Prep Course 2021.

*** Important Note: the recommendation from the candidate’s current direct supervisor must acknowledge endorsement of the time commitment required to attend the program. It is up to the candidate to communicate this requirement to their supervisor.

Please complete the information below and and contact each recommender and ask him or her to provide a letter to support your application.

Please provide the name of your recommender below.

Recommender's Name:(Required)

Recommender's Title:(Required)

Recommender's Employer:(Required)

Recommender's Phone Number:

Recommender's Email:

Attach Recommendation Letter (required):(Required)

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

To see if you qualify for the requirements of the CIC® Initial Certification, visit the Certification Board of Infection Control and Epidemiology. Inc. webpage and take their eligibility tool located at apps.cbic.org/certification-tools/eligibility-tool/index.php?slide=2

Questions? Contact Nina Costilla

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