Form

Thank you for your interest in the Certified Professional in Healthcare Quality^®️ (CPHQ) credential. To request an exam extension, please submit the form below and allow up to five (5) business days for a response.

First name*

Last name*

NAHQ ID*

Email*

I am unable to take the CPHQ exam during my eligibility timeframe due to:*

A natural disaster occurred within 30 days of this request.

A major life event occurred (death in the family, unplanned surgery) within the last 30 days.

Please provide a brief description of your situation to assist with the review process:*

Check this box to indicate you have read and understand the following statements.*

I understand that extensions are provided on a case-by-case basis and are not guaranteed.
I understand that I must complete this form at least five (5) business days before my scheduled exam and/or before my exam eligibility expires. I understand that if I do not submit this form within the designated timeframe, my request will be denied.
I understand that extensions, if approved, can only be provided ONE (1) time within each exam application.
I understand that requesting an extension for additional time to study will not be approved.
I understand that by submitting an extension request I may forfeit my fees to the exam if I have an upcoming scheduled examination that I do not cancel.
I understand that the maximum extension I can be given is 90 days or ONE (1) testing window from my exam eligibility end date.
I understand that my request may take at least five (5) business days to review.

Print Name*

Date*

Year/Month/Day