.0206 Course Provider Application

Complete the form below. Upload required documentation:

Facility Type	Resume	.0206 course completion certificate	.0206 course certificate OR Part 1 & Part 2 certificates	Current CIC
Outpatient	x		x	x
Dental	x	x
Home Health / Hospice	x	x

To apply to be a provider of the North Carolina .0206 Infection Control Curriculum, complete the form below and submit requested attachments.

Is this application for initial approval or renewal?
For which health care setting(s) do you want to be an approved provider?*
Name
First Last
Facility/Organization
Address 1
Address 2
City
State
Zip code
Email
Phone
Are you CIC Certified? (CERTIFICATION REQUIRED for OUTPATIENT APPLICANTS)*
CIC expiration date, if applicable (CERTIFICATION REQUIRED for OUTPATIENT APPLICANTS)
.0206 Course Certificate, if applicable
Max. file size: 50 MB.
IC Part 1 Certificate, if applicable
Max. file size: 50 MB.
IC Part 2 Certificate, if applicable
Max. file size: 50 MB.
Curriculum Vitae or Resume (all applicants)
Max. file size: 50 MB.
Dental Only: Dental Clinician Documentation (attach certification or license)
Max. file size: 50 MB.
Comments
By typing my name in the space below I agree to follow the approved provider instructions, to keep a record of all course participants, and to complete the Course Completion Form after every course.

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