Learning Outcome(s): This must match what you indicated in ...



APPROVED PROVIDER UNITEDUCATIONAL ACTIVITY PLANNING FORMApproved Provider InformationName: Address:Contact Phone: Title of Activity Click here to enter text.Activity Date: Additional Date(s) (if applicable): Activity Location: Activity Type? Provider-directed, provider-paced: Live (in person or webinar)Date of live activity: Click here to enter a date.Location of activity: Click here to enter a date. ? Provider-directed, learner-paced: Enduring materialStart date of enduring material: Click here to enter a date.Expiration/end date of enduring material: Click here to enter a date.? Learner-directed, learner-paced: Enduring materialStart date of enduring material: Click here to enter a date.Expiration/end date of enduring material: Click here to enter a date.? Blended activityDate(s) of prework and/or post-activity work: Click here to enter a date.Date of live portion of activity: Click here to enter a date.NARS Reporting Conversion TermsThis section is included to assist with NARS data entry. Below is the list of terms and all information necessary to “open” and “close” an activity in the information tracking system. Please indicate the type of activity.NARS Activity Type? Course—A live educational activity where the learner participates in person? Internet Live Course—An online course available via the Internet at a certain time on a certain date and only available in real-time? Regularly Scheduled Series (RSS)—A course that is planned as a series with multiple, ongoing sessions? Journal Based CNE—An activity that includes the reading of an article (or adapted formats for special needs)? Other—An activity that may be a Manuscript Review, Test Writing Item, Committee Learning, Performance Improvement, Internet Searching and Learning, etc.Nurse Planner Contact Information for This Activity Note: The Nurse Planner must be a registered nurse who holds a current, unencumbered nursing license (or international equivalent) AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education activity.Acceptable Example: Name, PhD, MSN, RN Name, PhD, BSN, RN-BCInappropriate Example: Name, PhD, RN as PhD might not be in nursing and RN does not indicate the academic level of the nursing degree)Name and credentials: Click here to enter text.Licensing State(s): Click here to enter text.Email Address: Click here to enter text.Phone number: Click here to enter text.Education Needs Identification and Assessment of Learner NeedsDescription of The Professional Practice Gap (e.g. change in practice, problem in practice, opportunity for improvement)Current State (What is currently happening)Desired State(What should be happening)Identified Gap(Difference between what is and should be happening)Evidence to Validate The Professional Practice Gap (check all methods/types of data that apply)? Survey data from stakeholders, target audience members, subject matter experts or similar? Input from stakeholders such as learners, managers, or subject matter experts? Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement? Evaluation data from previous education activities? Trends in literature, law and/or health care? Trends in practice, treatment modalities and/or technology? Direct observation? Other—Describe: FORMTEXT ?????Brief Summary of Data Gathered That Validates the Need for This Activity (information gathered to help to substantiate the need for this event)Educational Need That Underlies The Professional Practice Gap (e.g. knowledge, skill and/or practices)Choose an item.Education Design ProcessDescription of The Target Audience (You can select more than one target audience.) Choose an item. Choose an item. Choose an item. Choose an item. Desired Learning Outcome(s) - While a goal gives a general statement of your program's purpose,?objectives?are more concrete and specific in how the goal will be achieved. This is not about goals and objectives but about outcomes. Outcomes?should reflect what is the expected as a result of your CE event. What will the learner’s outcome be as a result of participation in this activity? Clear articulation of learning outcomes serves as the foundation to evaluating the effectiveness of the teaching and learning process.). For example, “As a result of this activity, the learner will…”Area of impact (check all that apply):? Nursing Professional Development ? Patient Outcome? Other- Describe: FORMTEXT ?????Outcome Measure(s) - A quantitative statement as to how the outcome will be measured to assess the impact of this educational activity in closing the identified gap. Focus on attendee behavior, use simple, specific action verbs, select appropriate assessment methods that are measurable, and state desired performance criteria that relate to the gap in knowledge, skill, and/or practice. For example, to measure a change in knowledge, a pre- and/or post-test may be used. To measure a change in skill and/or practice, return demonstrations, role-playing, case reviews, etc. may be utilized. Content of Activity (A description of the content with supporting references or resources)? See Educational Planning Table OR [Attachment 1]? Or describe content and include time calculation for content: Click here to enter text. Content for this educational activity was chosen from:? Information available from the following organization/web site (organization/web site must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content; examples – Agency for Healthcare Research and Quality, Centers for Disease Control, National Institutes of Health): FORMTEXT ?????? Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years): FORMTEXT ?????? Clinical guidelines (example - ): FORMTEXT ?????? Expert resource (individual, organization, educational institution) (book, article, web site): FORMTEXT ?????? Textbook reference: FORMTEXT ?????? Other: FORMTEXT ?????Nurse Planner Assessment of Content for Commercial Interest* Relevance*Commercial interest,as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. (i.e. pharmaceuticals, supplements, botanicals, neutraceuticals, essential oils, medical devices, and medical equipment products.) "Conflict of Interest exists when an individual is in a position to control or influence the content of an education activity and has a financial relationship with a commercial interest organization the products or services of which are pertinent to the content of the educational activity."Describe the process utilized by the NP to determine if a conflict of interest exits for speakers and educational planning committee members. How is the NP assessing for potential COI? The response requires you to focus on how the NP addresses these 3 questions about the activity:Does the activity include content related to a commercial entity’s products and/or services?Is the individual on the planning committed in a position to control content?Has the individual (or their significant other) had a financial relationship with a commercial entity in the past 12 months?As the NP assesses potential COI, the answer to ALL 3 of these questions must be “YES.” If the answers to all 3 questions above is YES, COI must be assessed, evaluated, and resolved. That process must be described in the box below. If ANY answer is “NO” then COI does not need to be assessed and you can skip to the “NO” option and select it. Click or tap here to enter text.? Yes, this educational activity includes content related to the products and/or services of a commercial interest entity by ANCC definition. If “YES” is selected, a conflict of interest (COI) form must be included in [Attachment 2] for each individual listed in Table I who has a financial relationship with a commercial interest entity relevant to this activity's content. Generally, clinical content means that “Yes” is selected here and all persons in a position to control content must be assessed for potential COI. Using generic terms instead of brand names for the product, services, or equipment does not exempt the content from potential for COI with a commercial interest organization that makes that type of product.. Examples of content that DOES require COI forms to be completed includes the following: Stages of Breast Cancer and Current Treatment ModalitiesFall Prevention and Equipment SolutionsWound Care Pain Management Options ? No, this educational activity does not (1) include any content related to the products and/or services of a commercial interest entity; (2) does not include an individual (or their significant other) in a position to control content who has a relationship with a commercial entity within the last 12 months and so does not require COI forms for the planners or presenters. Examples of content that does not require COI assessment includes the following:Non-clinical content such as Staff Development Methods; Outcome Measures; Leadership Skills;Clinical content without product-related treatments discussions such as “Understanding Hemodynamic Mechanisms”; “EKG Interpretation”; “Cultural Diversity”.Explain below why content is considered exempt for COI:Nurse Planner SignatureI attest that I have reviewed the biographical information and actual/potential conflict of interest for each member of the planning committee members, content experts, content reviewers, authors, faculty, speakers, and presenters for the event and there are NO conflicts of interest to disclose. _______________________________________________________________________ Typed or Electronic Signature: Name and Credentials (Required) DateIndividuals in a Position to Control ContentComplete the table below listing each person in a position to control content of the educational activity. Include name, credentials, educational degrees(s), role in the activity, and any financial relationships with a commercial interest entity that is relevant to the content.There must be at least two people—one Nurse Planner and one other planner—to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert) and can also be the Nurse Planner or a Presenter who is on the Planning Committee. The individuals who fill the roles of Nurse Planner and Content Expert must be identified.Columns D, E, and F relate to the nurse planner's assessment of Conflict of Interest for the individuals in column A.For questions about how to assess for conflict of interest for columns D, E, and F review the ANCC Standards (specifically Section F) of ANCC Content Integrity StandardsABCDEFGName of individual and credentialsRole(s) in activityNurse Planner (only one)Content ExpertOther PlannerPresenter/AuthorPlanning committee member? (Yes/No)Content Related to Commercial Interest Entity?(Yes/No)Commercial interest relationship?(Yes/No)If yes in E Name of Commercial Interest and nature of relationshipIf yes in C, D, AND E, Attached COI form(Yes or n/a)Example: Jane Smith, BSN, RNNurse PlannerYesNon/an/aExample: Sue Brown, PhD, RNContent ExpertYesNon/an/aExample: Ida Row, MSN, RNOther PlannerYesNon/an/aExample: John Doe, MDPresenterNoYesPfizer Speakers BureauYesAdd rows as neededDescribe how it was determined that the Nurse Planner and Content Experts are qualified for these roles: Provide information about NP expertise/education in adult education or adult learning and ANCC credentialing criteria.Describe professional experience or areas of expertise, which contribute to content expertise for this activity. May include educational background, professional/practice experience, and publications. (Provide detailed information supporting why this person has been deemed an expert in the field)Learner Engagement Strategies? See Educational Planning Table OR ? Integrating opportunities for dialogue or question/answer? Including time for self-check or reflection? Audience response system? Analyzing case studies? Providing opportunities for problem-based learning? Pre/Post Test? Other: FORMTEXT ?????Contact Hour CalculationContact hours must be determined in a logical and defensible manner, and awarded to participants for those portions of the educational activity devoted to learning and evaluation. One contact hour = 60 minutes. Fractions or portions of the 60-minute hour can be awarded. For example, 135 minutes equals 2.25 contact hours. Contact Hours Awarded may be rounded to the nearest quarter. (e.g. 2.78 may be 2.75 contact hours, 2.9 may be 3.0 contact hours)Time for registration, introductions, opening announcements, breaks, meals, business meetings and viewing of exhibits are NOT included in the calculation of contact hours. Viewing of poster sessions and evaluations may be included but require a defensible method for calculations.If activity is more than 3 hours (from registration to closing) attach an educational planning table or a detailed agenda (Attachment 1) for the entire educational activity.Enter the maximum number of contact hours a participant could earn for this activity: FORMTEXT ????Identify the method used to calculate the number of contact hours awarded to each participant:?Total number of eligible minutes for each session attended divided by 60 ? Pilot study – average time for completion of activity by testers? Historical data – compared this activity to a similar existing enduring material activity? Professional opinion based on complexity of content and delivery method? Mergener Formula used for text content Number of Words FORMTEXT ????Number of Questions FORMTEXT ????Degree of Difficulty FORMTEXT ???? ? Other (Describe): FORMTEXT ????Criteria for Awarding Contact HoursCriteria for awarding contact hours for live and enduring material activities include: (Check all that apply) ?Attendance for a specified period of time required. ? 100% attendance for entire event ? May attend partial event (i.e. conferences)? Other: Describe here: FORMTEXT ?????? Contact hours awarded for actual hours attended (requires tracking of attendance per conference day, per plenary and breakout sessions. This option allows for partial credit.) ? Completion/submission of evaluation form ? Successful completion of a post-test (e.g., attendee must score FORMTEXT ?????% or higher)? Successful completion of a return demonstration ? Other - Describe: FORMTEXT ?????Description of Evaluation Method: (How will change in knowledge, skills, and/or practice be evaluated at the end of this activity? Refer back to identified practice gap and educational need. Evaluation must occur at the level of need identified in “C” above).A clearly defined evaluation method includes learner input used to assess the effectiveness of the educational activity. The evaluation components and method of evaluation should relate to the desired learning outcome of the educational activity. Evaluation methods may include both short term and long term. (Sample Participant Evaluation Form available on )Evaluation methods may include both short term and long term. Short-Term Evaluation Options (How will this information be gathered and results analyzed at the end of the CE event?)? Participant evaluation with self-report Intent to change practice? Active participation in learning activity? Post-test? Return demonstration? Case study analysis? Role-play? Other – Describe: FORMTEXT ????? Long-Term Evaluation Options (This is not required but if long term evaluation will be conducted, you must describe how the information will be gathered and results analyzed to determine impact of the CE event over time at a specific interval after the event has been completed?)? Self-reported change in practice? Change in quality outcome measure? Return on Investment (ROI)? Observation of performance? Other – Describe: FORMTEXT ????? Summative Evaluation: [Attachment 6]Documentation after the event must summarize:total number of participantscontact hours earned by each participantpertinent findings from the participant feedback, comments, and suggestions for future topics documentation by the nurse planner of need for any follow up action steps and actions takenATTACHMENTS(It is highly recommended that you use the following attachment templates for your programs.)Please provide evidence of the following:Attachment 1Educational Activity Planning Table with full agenda timeline from registration to closingAttachment 2Conflict of interest documentation from all individuals in a position to control content (e.g. planners, presenters, faculty, authors, and/or content reviewers) and resolution if applicable ORa statement that COI documentation is not required because the content of the activity has no relationship to products or services of a commercial entity (consumed by or used on patients)Attachment 3Certificate of completionAttachment 4Commercial Support Agreement with signature and date (if applicable)Attachment 5Disclosures/Evidence of required information provided to learners prior to start of the activity:Activity approval statement as issued by the accredited approverCriteria for successful completion in order to receive contact hoursPresence or absence of conflicts of interest for all individuals in a position to control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers) If COI is present, disclosure must include name of person, type of relationship, and name of commercial mercial support (only if applicable)Expiration date (enduring materials only)Name(s) of Joint Provider(s) (only if applicable)NOTE: (Materials associated with the activity (marketing materials, advertising, agendas, and certificates of completion) must clearly indicate the Provider awarding contact hours and responsible for adherence to ANCC criteria)Attachment 6Summative Evaluation and a copy of any participant evaluation forms usedCompleted by: _____________________________________________________________Date: _____________________________________________________________ATTACHMENT 1EDUCATIONAL ACTIVITY PLANNING TABLE[Approved Provider Name]Educational Planning Table and AgendaTitle of Activity: Learning Outcome(s): This must match what you indicated in section E.TIME ALLOTMENT* LIST EACH SESSION TITLE & PRESENTERCONTENT (Topics)Provide an outline of the contentTEACHING METHODS/LEARNER ENGAGEMENT STRATEGIESStart TimeStop TimeTotal Minutes15Introduction60TitlePresenter Name15Break45TitlePresenter Name45TitlePresenter Name60Lunch45TitlePresenter Name45TitlePresenter Name15Closing and evaluationAdd rows as neededTotal Agenda Minutes*345Add all minutes including NON-CE content minutes, introductions, breaks and mealsTotal Contact** Minutes255Total minutes ___345______minus total NON-CE minutes_90_____divided by 60 = _____4.25___contact hours*Include introductions, breaks, & meals and non-CE content time but do not count in total contact minutes**Time spent evaluating the learning activity may be included in the contact minutes when calculating contact hours.ATTACHMENT 2 CONFLICT OF INTEREST FORMApproved Provider's Name: If it has been determined by the NP that no conflict of interest exists for this activity, COI documentation is not required because the content of the activity has no relationship to products or services of a commercial entity (consumed by or used on patients). The process for determination should be described in section H in the application.If there is potential for a COI for this event, a COI form must be competed for all presenters and members on the educational planning committee, including a COI for the Nurse Planner that has been reviewed by another planning committee member. Title of Educational Activity: FORMTEXT ?????Educational Activity Date: FORMTEXT ????? Role(s) in Educational Activity: (Check all that apply) FORMCHECKBOX Nurse Planner FORMCHECKBOX Content Expert FORMCHECKBOX Faculty/Presenter/Author FORMCHECKBOX Content Reviewer FORMCHECKBOX Other PlannerSection 1: Demographic DataName with Credentials/Degrees: ________________________________________________________If RN, check all Nursing Degree(s) held: FORMTEXT ????? AD FORMTEXT ????? Diploma FORMTEXT ????? BSN FORMTEXT ????? Masters FORMTEXT ????? DoctorateCurrent Employer Position/TitlePhone number:Email Address:Mailing Address City, State and Zip CodeSection 2: Conflict of InterestThe potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity. *Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. (Please reference content integrity document for further clarity)All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity. Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest. Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner? FORMTEXT ????? Yes FORMTEXT ????? NoIf yes, please complete the table below for all actual, potential or perceived conflicts of interest.** Check all that apply:CategoryDescriptionSalaryRoyaltyStockSpeakers BureauConsultantOther* *All conflicts of interest, including potential ones, must be resolved with the nurse planner prior to the planning, implementation, or evaluation of the continuing nursing education activity.Section 3: Statement of UnderstandingCompletion of the line below serves as the electronic signature of the individual completing this Conflict of Interest Form and attests to the accuracy of the information given above. ______________________________________________________________________________Typed or Electronic Signature: Name and Credentials (Required) DateSection 4: Conflict Resolution (to be completed by Nurse Planner)Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply) FORMTEXT ???? Not applicable since no conflict of interest. FORMTEXT ???? Removed individual with conflict of interest from participating in all parts of the educational activity. FORMTEXT ???? Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the educational activity. FORMTEXT ???? Not awarding contact hours for a portion or all of the educational activity. FORMTEXT ???? Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation. FORMTEXT ???? Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity. FORMTEXT ???? Other - Describe: FORMTEXT ????-28956099695Nurse Planner Signature (*If this form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign).Completion of the line below serves as the electronic signature of the Nurse Planner reviewing the content of this COI Form. _______________________________________________________________________ Typed or Electronic Signature: Name and Credentials (Required) Date00Nurse Planner Signature (*If this form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign).Completion of the line below serves as the electronic signature of the Nurse Planner reviewing the content of this COI Form. _______________________________________________________________________ Typed or Electronic Signature: Name and Credentials (Required) Date ATTACHMENT 3 CERTIFICATE OF COMPLETIONAttach a sample of your Certificate of CompletionYour certificate must include these ANCC required elements:Name and address of the provider of the educational activity (web address is acceptable)Participant name Title and date of the educational activityNumber of contact hours awardedApproval statement[insert your provider unit name] is an approved provider of nursing continuing professional development by the Continuing Nursing Education Group, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.ATTACHMENT 4 COMMERCIAL SUPPORT AGREEMENT(S)Attach any Commercial Support Agreement(s) if applicableMay use CNEG or the Commercial Interest Organization's preferred agreement.ATTACHMENT 5 DISCLOSURESComplete all applicable disclosures (provided to learners prior to start of the activity)Complete items 1-6 under Action.Remove verbiage or other items that do not apply (such as Expiration Date or Joint Provider information)Activity Title:Activity Date:DisclosureActionApproval Statement [insert your provider unit name] is an approved provider of nursing continuing professional development by the Continuing Nursing Education Group an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.Criteria for Successful CompletionInsert participant requirements to receive contact hours.Conflicts of Interest Presence or absence of conflicts of interest for all individuals in a position to control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers)MUST CHOOSE ONE and delete the others:This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest. ORNo individuals in a position to control content for this activity has any relevant financial relationships to declare.ORThe following individuals in a position to control content for this activity declare they have a commercial interest relationship relevant to the content of this activity and it has been resolved with the nurse planner. _____NAME_____________(insert the type of relevant financial relationship). Examples:Ann Jones, RN is on the Speaker's Bureau for XYZ Company.Ralph Emerson owns stock in XYZ Company Commercial Support(Insert Name of Commercial Interest) providing financial or in-kind support for this activity and signed a commercial support agreement:ORThere is no commercial support being received for this event.Expiration date for Enduring Materials if applicableOrigination Date: insert the dateExpiration Date: insert the dateJoint Provider(s) if applicableThis activity is being jointly provided by [Insert Activity Provider Name] and [insert Joint Provider Organization's name(s)].If using verbal disclosures, a written attestation form must be completed and signed by an audience member (not a nurse planner or program facilitator) indicating what disclosures were provided. ATTACHMENT 6 SUMMATIVE EVALUATIONProvider's Name: Activity Title:Activity Evaluation Date: Awarded Contact Hours: Activity Participation/Comments: Attach list of participants and indicate the number of contact hours awarded each individual (i.e. number of participants, more or less than expected, demographics, etc.) Total # Total # receiving full credit:List of Participants receiving partial credit and amount:Jane Doe (i.e. 6 of 8) John Smith (i.e. 2 of 8)Comments:Activity Schedule/Delivery Comments: (i.e. live event comments, online activity, etc.)Participant Evaluation Comments: (i.e. content, instructors, bias, quality of program, test question revisions, etc.)Participant Ratings Summary: (of all evaluation items)Overall Recommendations/Key Findings Action Planexample - 100% rated 5/5 example - 65% desired more Q/A in Session 4example - continue without changesexample - instruct speaker to increase Q&A time in Session 4Nurse Planner Signature (Required): Date: ................
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