SOCIETY OF TRAUMA NURSES



APPLICATION CHECKLIST

(submit to STN headquarters @ least 3 months prior to event)

Application Form

Application Fee

Biographical Data Form for each planning committee member

Biographical Data Form for each presenter

Presenter Participation Form for each presenter

Typed program outline, or draft of brochure

Copy of evaluation form

Copy of Certificate of Completion

POST EVENT SUBMISSION CHECKLIST

(submit to STN headquarters within 45 days of event completion)

Evaluation Summary, including number of respondents

Completed Attendance Roster

Final brochure

APPLICATION FOR CONTINUING EDUCATION

This application was developed in accordance with standards and criteria set forth by policies and procedures of the California Board of Registered Nursing (BRN) continuing education program through whom The Society of Trauma Nurses is an approved provider.

SUBMITTED BY:        DATE SUBMITTED:       

APPROVED BY:        DATE APPROVED:       

PROGRAM TITLE:       

DATE(S) OFFERED:      

# CONTACT HOURS (50 min. presentation = 1 contact hour):     __________________

LOCATION (must meet ADA requirements):        

_______________The above section for administrative use only_____________

Application to be completed and submitted to the Society of Trauma Nurses (STN) at least 45 days before the program date.

I. ADMINISTRATIVE CRITERIA

A. Program Title: _____________________________________________________________

B. Date(s) Offered: ________________________________

C. STN Education Committee Planning Member:       

D. Contact person for educational activity:       ext:       

E. Planning committee members (List names/ credentials here): At least one person must be an RN with a Baccalaureate or higher degree in nursing. If there are more than six members, submit on a separate sheet of paper.

1.       

3.       

5.       

2.       

4.       

6.       

II. EDUCATION CRITERIA

A. Target audience (must include registered nurses):

      

B. Needs assessment (check all that apply):

| Expressed need (written or verbal) | | Nursing education | | Literature reviews |

|Program evaluations | |Nursing management | |Reviews of current or future trends or |

|Survey | |Observation of | |standards of practice |

|Quality / Patient Safety | |practice | |Changing patient population |

| Other (please specify): |

|       |

C. Overall Program Goal/Purpose:       

For education which includes vendor displays, the following statement must appear on the brochure: The Society of Trauma Nurses is a licensed continuing education provider by the Sate of California Board of Registered Nursing, Provider Number 11062. The STN has approved this course # _____ for _____ hours of continuing education.

For the educational activity: submit brochure or outline, listing each topic area and its time frame. Please include breaks, lunch, and evaluation time (30 min. recommended)

D. Adult learning principles (check all that apply):

| Recognizes autonomy | | Uses inquiry focused activity |

| Recognizes readiness to learn | | Recognizes the need to share |

| Utilizes previous experience | | Meets comfort needs |

| Uses problem oriented approach | | Involves learner evaluation |

| Uses experiential learning activity | | Will use additional on-site needs assessment |

| Other (specify): |

|    |

E. Verification of Participation

1. Participants attendance at each educational activity must be verified before awarding the individual Certificate of Completion and contact hours

2. Participants must sign an Attendance Roster (sample attached).

F. Verification of Successful Completion

1. Participants' completion of each educational activity must be verified before awarding the individual continuing education contact hours

2. Methods used to determine successful completion of the educational activity will include:.

Signature on roster

Completed written post-test

Return of evaluation tool

Return demonstration

Discussion with presenter(s)

Attendance at entire activity

Self-reported report of objectives achievement

Other (describe)       

G. Physical Facilities - Describe the physical facilities for this activity. Indicate that the Physical Facilities are:

Accessible to target audience

Room set-up appropriate for type of educational activity

Able to accommodate projected number of participants

Environmentally comfortable

H. Enclosure Checklist

Application Form (two pages)

Biographical Data Form for each planning committee member.

Biographical Data Form for each presenter.

Presenter Participation Form for each presenter.

Typed program outline, or draft of brochure

Copy of evaluation form.

Copy of Certificate of Completion.

I. Documentation to be provided to STN headquarters after event completion

Evaluation Summary, including number of respondents

Completed Attendance Roster

Final brochure

BIOGRAPHICAL DATA FORM

Instructions: DUPLICATE THIS FORM AS NECESSARY. Information for each person must be typed directly on this form. DO NOT submit a resume or curriculum vitae in lieu of or in addition to the Biographical Data Form. Wording such as “see attached” will not be accepted on the Biographical Data Form. The Biographical Data Form should focus on the unique qualifications of this faculty member to present the assigned material.

Name / Credentials:      

Preferred Address:      

City:        State:        Zip:       

Day Telephone:        Ext.        E-Mail:        

Present Position (Employer, Title and Description):       

Education (Include basic preparation through highest degree held):

| |Degree |Institution (name, city, state) |Major Area of Study |Year Degree Awarded |

|1. |       |    |   |      |

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|2. |       |    |   |      |

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|3. |       |    |   |      |

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|4. |       |    |   |      |

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Describe your professional experience or areas of expertise related to your role in the educational activity:

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CONFLICT OF INTEREST STATEMENT

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity.

I recognize that I must follow all guidelines and criteria regarding vested interest. Any real or perceived conflict of interest for a conference participant must be disclosed. For this purpose a real or apparent conflict of interest is defined as having a significant financial interest in a product to be discussed directly or indirectly during the presentation; being or having been an employee of a company with such financial interest and/or having had substantial research support by an industry to study the product to be discussed at the presentation.

A. Is there a potential conflict of interest? Yes No (If yes, list company(ies) with relationship below)

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|     |

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B. Discussion of off-label uses: Yes No (If yes, I agree to inform learners of such.)

ALL information disclosed must be shared with the audience either on program handouts, advertising and/or audiovisual presentation.

Signature:        Date:       

(Signature required)

( By checking this box, I am providing my electronic signature approving all the information entered above (if choosing the electronic signature options please type name and date on the signature and date lines provided above).

PRESENTER PARTICIPATION FORM

Name:       

A. Check how you, the presenter, are involved in planning and evaluating this presentation. (Check all that apply)

Discussed with planners the needs of the target audience

Developed and /or provided input on objectives

Established content

Will review evaluation(s) / summary

B. I plan to use the following learning principles in my presentation. (Check all that apply)

Establish a “need to know” of participants

Incorporate the use of various senses: sight, sound (AV, Hand-Outs), touch (doing)

Engage audience in discussion based on content

Use multiple teaching techniques to meet various learning styles of participants (lecture, discussion, Q&A)

Incorporate target audiences past experiences

Establish a positive environment for learning

Other (specify)       

C. All presenters must declare any conflict of interest in order to ensure that all continuing education activities are free from bias.

Verbal statement during the presentation

Information provided on handouts

Information provided in audiovisuals (slides, overhead, PowerPoint, etc.)

Other (describe):

NA

DOCUMENTATION FORM

Title of educational activity:       

|OBJECTIVES | | | | |

| |CONTENT DESCRIPTION |TIME FRAME |PRESENTER |TEACHING STRATEGIES |

|List the educational objectives for each |Provide an outline of the content / topic |Provide a total time frame for this |List the presenter for each topic or |List the teaching strategies used by each |

|presenter which define the expected outcomes |presented and indicate to which |presenter |content area |presenter for all topic or content areas |

|for the learner |objective(s) the content / topic is | | | |

| |related | | | |

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*Submit information for the entire activity.

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|Attendance Roster |

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|Program Title:     |Program Date:        |

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|Location:       |Start Time:        |End Time:        |

|Instructor(s):      |Course Number:      |

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| |Name (please print): |Signature |Facility or Hospital Name and State |

|Example |First Name, Last Name | |Hospital Name, Anywhere USA |

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SOCIETY OF TRAUMA NURSES

1020 Monarch Street, Suite 300B

Lexington, KY 40513

STN Provider Number: 11062

Program:       

Date:       

Overall Goal/Purpose:       

Please rate the following:

5 = Excellent (E), 4 = Very Good (VG), 3 = Good (G), 2 = Fair (F), 1 = Poor (P)

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|Session |Title: |E |VG |G |F |P |

| | | | | | | |

|Speaker: (name) |Teaching Effectiveness |5 |4 |3 |2 |1 |

| | | | | | | |

| |Knowledge of subject matter |5 |4 |3 |2 |1 |

| | | | | | | |

| |Organization of content |5 |4 |3 |2 |1 |

| | | | | | | |

| |Appropriateness of Teaching Methods |5 |4 |3 |2 |1 |

| | | | | | | |

|Objectives Met by Learner |Objective #1: |5 |4 |3 |2 |1 |

| | | | | | | |

| |Objective #2: |5 |4 |3 |2 |1 |

| | | | | | | |

| |Objective #3: |5 |4 |3 |2 |1 |

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|Objectives Related to Overall | |5 |4 |3 |2 |1 |

|Goal/Purpose | | | | | | |

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|Comments: |

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Please circle appropriate number:

1. Did the learner meet goal/purpose? 5 4 3 2 1

2. Were physical facilities appropriate? 5 4 3 2 1

3. How will this information influence your care?

4. Did you perceive any financial conflict of interest or commercial bias related to this presentation that was not previously disclosed?” No Yes (please explain)

5. Suggestions for improvements and additional comments:

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