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CHILDRENS OF ALABAMAACTIVITY APPLICATIONGeneral InformationChildren’s of Alabama (COA) is an Approved Provider of continuing nursing education by the Alabama Board of Nursing (ABN): ABNP0113, Expiration Date: 06/29/2021.Children’s of Alabama is approved as an approved provider of continuing nursing professional development by The Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation: Provider Number: 5-173, Expiration Date: 02/01/2022.Approval time period is two (2) years.?Applications are accepted for programs / activities coordinated by Children’s of Alabama employees, provided to Children’s of Alabama employees or for programs / activities available for Children’s of Alabama employees to attend.Application must contain all information before review and approval may be granted. Should you need assistance contact Ann Bentley, BSN, RN, NPD-BC, CPN (ann.bentley@) at 205-638-6941 or nursingcontinuingeducation@. See the following policies for additional information: PROVIDER Information:CONTACT PERSON DEPARTMENTADDRESSCITYSTATEZIP CODEDAY PHONEEMAILright114935The 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.00The 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.NURSE PLANNER (name and credentials)TITLE/POSITIONDEPARTMENTDAY PHONEEMAILALABAMA LICENSE NUMBER:Activity Type: ? Provider-directed, provider-paced: Live (in person or internet live)Date(s), time(s) and location(s) of live activity: __________________________________________________________________________________________________________________________________Minimum number of learners: ___________Maximum number of learners: __________? Provider-directed, learner-paced: Enduring material (CBT, recorded presentation, etc.)Start date of enduring material: ______________Expiration/end date of enduring material: _____________? Journal ClubIs participant required to read article prior to live presentation? If so date(s) article is available: ____________Date(s), time(s) and location(s) of live portion of activity: _________________________________________________________________________________________________________________________Minimum number of learners: ________________________________Maximum number of learners: ________________________________? Blended activityDate(s) of enduring materials (e.g. prework): ____________Date(s), time(s) and location(s) of live portion of activity: _________________________________________________________________________________________________________________________Minimum number of learners: ________________________________Maximum number of learners: ________________________________Title of Activity: (no longer than 77 characters)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Description of activity: _______________________________________________________________Number of Contact Hours Requested: ABN: ______ ANCC: ______ Number of Pharmacy Contact Hours Request:ABN: ______ ANCC: ______ ABN = Total minutes divided by 50 ANCC = Total minutes divided by 60Programs with multiple sessions:If individuals can come for all day or just attend one session or if a session will be presented separately later, then each session will be assigned an activity number and CEs. List individual sessions below.Title (No more than 77 characters)Brief Description of ActivityContact Hours Requests PharmacyABNANCCABNANCCLogistic Information (Answer all questions)YesNoWill this Activity be part of a seriesWill this activity be presented via internet live method? Ex: ZOOMWill this activity be recorded to be viewed later? (If so, recorded activity will be assigned a separate activity number and CEs) Contact isthelp@ to assist with recording if needed.Will participants register for this event in Children’s University?Will the ABN license scanner be needed? If so when do you want to pick it up from Nursing Education:Will CE certificates be needed? (Certificates are only required for non-COA employees with an out of state license) NARS Reporting Criteria (check only those that apply):Interprofessional Education Collaborative:______Values/Ethics for Interprofessional Practice______Roles/Responsibilities______Interprofessional Communication______Teams and TeamworkInstitute of Medicine:______Provide patient-centered care______Work in interdisciplinary teams______Employ evidence-based practice______Apply quality improvement______Utilize informaticsACGME/ABMS:______Patient Care and Procedural Skills______Medical Knowledge______Practice-based Learning and Improvement______Interpersonal and Communication Skills______Professionalism______Systems-based PracticePTCB______Pharmacology for technicians_____Pharmacy laws and regulations______Sterile and non-sterile compounding_____Medication safety______Pharmacy quality assurance______Medication order entry and fill process______Pharmacy inventory management______Pharmacy billing and reimbursement______Pharmacy information systems usage and applicationCAPE:______Learner______Patient-centered care______Medication use systems management______Health and wellness______Population-based care______Problem solving______Educator______Patient Advocacy______Interprofessional collaboration______Cultural sensitivity______Communication______Self-awareness______Leadership______Innovation and entrepreneurship______ProfessionalismArea of Impact/Designed to Change: ? Competence ? Performance ? Patient Outcomes? Nursing Professional Development ? Other __________________________Will changes be evaluated??Yes?No Competence If yes, how? _________________________________________?Yes?No Performance If yes, how? _________________________________________?Yes?No Patient Outcomes If yes, how? _________________________________________Description of the professional practice gap: (e.g. change in practice, problem in practice, opportunity for improvement)Describe the current state:Describe the desired state:Identified gap: (knowledge/skills/practice/other: describe)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 health care? Direct observation? Other – Describe: __________________________________________________Please provide a brief summary of data gathered that validates the need for this activity:Educational need that underlies the professional practice gap _____Knowledge_____Skill _____PracticeDescription of the target audience. (You may select more than one target audience)._____RN_____LPN_____Advanced Practice_____Other _____________Desired learning outcome(s). (The objective) The learning outcome flows from the needs assessment addressing knowledge, skills, and/or attitudes and must be action oriented, observable, and measurable. Who, what action, and results are stated (What will the outcome be as a result of participation in this activity? What will the learner know or be able to do?) Outcome Measure(s) (A quantitative statement as to how the outcome of this activity will be measured):Content of activity: A description of the content with supporting references or resources. Located on Educational Planning Table Content for this educational activity was chosen from (provide references on Educational Planning Table or on a separate page):? 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): ____________________________________? Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years): ______________________________________________________________? Clinical guidelines (example - ): ________________________________? Expert resource (individual, organization, educational institution) (book, article, web site): _________________________________________________________? Textbook reference: _________________________________________________________? Other: FORMTEXT ?________________________________________________________________????Learner Engagement Strategies: Incorporate the following strategies on the Educational Planning Table. Include a copy of your instrument (i.e. exam/test with answers, return demonstration checklist, etc.) ? Integrating opportunities for dialogue or question/answer? Including time for self-check or reflection? Analyzing case studies? Providing opportunities for problem-based learning? Pre and/or Post Test? Games? Role Play? Return Demonstration Check Sheet? Other: FORMTEXT ?????____________________________________________________Criteria for Awarding Contact HoursCriteria for awarding contact hours for live and enduring material activities include:Internet live, recorded and enduring material require post-test (Check all that apply) ?Attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity) – Be specific: FORMTEXT ?????__________________________________?Credit awarded commensurate with participation?Attendance at 1 or more sessions ?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: Evidence that change in knowledge, skills, and/or practices of target audience was assessedEvaluation tool to be used:_____ The COA Single Event with Single Presenter Evaluation _____ A different evaluation form (include copy)_____ Evaluation questions and evaluation contained in computer based learning module.Short-term evaluation options:? Intent to change practice? Active participation in learning activity? Post-test? Return demonstration? Case study analysis? Role-play? Learner met personal objectives for participation? Learner will identify methods to apply knowledge? Other – Describe: _____________________________________________________ Long-term evaluation options: (Not required, if used results must be sent to Nursing Professional Development within 2 weeks from occurring unless notifying NPD of change in plans)? None? Self-reported change in practice? Change in quality outcome measure? Return on Investment (ROI)? Observation of performance? Unable to apply knowledge due to (describe): __________________? Other – Describe: ___________________________________________________ When will long term evaluation occur ? 30 days? 60 days? 90 day? 6 months? other _______________Advertisement of Activity: (submit copy of external/out of hospital advertisement with application)This activity will be advertised through the following method(s):_______ Verbal, email and other one-to one-communication strategies_______ Intra-hospital notification _______ External or outside the hospital COMMERCIAL SUPPORTWill activity receive commercial support?_________ Yes (describe how integrity of activity will be maintained)________ NoIndividuals in a Position to Control ContentComplete the table below for each person in a position to control content of the educational activity. Must have at least one Nurse Planner and one other planner to plan each educational activity. Other roles include Content Expert and Speaker. A person can serve in more than one role. Ex: The Nurse Planner could also be the Presenter and the Content ExpertIdentify the following roles:Nurse Planner Knowledgeable of the CNE process and is responsible for adherence to the ANCC criteriaReviews and signs included COI forms, excluding their own One other planner - Reviews and signs the Nurse Planners COI formContent Expert – Is one of the planners and needs to have appropriate subject matter expertise for the educational activity being offered Presenter(s)Name of individual and credentialsIndividual’s role in activityPlanning committee member? (Yes/No)Name of commercial interestNature of relationshipExample: Jane Smith, RN-BCNurse Planner, Content ExpertYesNone---Example: Sue Brown, RNCPlannerYesNone---Example: John Doe, PhDPresenterNoPfizerSpeakers Bureau Completed by: ________________________________________________________________________Date: _____________________________________________________Disclosure Information and Example – This page does not have to be included with application.Must include copy of Disclosure with ApplicationRequired InformationAccreditation?statementsChildren’s of Alabama is approved by the Alabama Board of Nursing as a provider of continuing education in nursing. ABNP0113; Expires: 06/29/2021The Children’s Hospital of Alabama/Children’s of Alabama is approved as a provider for nursing continuing professional development by The Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Provider number 5-173; Expires 02/01/2022Criteria for awarding 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)Commercial support (if applicable)Expiration date (enduring materials only)Example:Disclosures:This activity meets the criteria for ___ABN and ___ ANCC nursing continuing professional development hours. In addition, ___ ABN and ___ ANCC pharmacy nursing hours have been assigned to this course. Individuals are expected to stay for the entire activity, participate in the discussions and activities, sign the roster (documentation of attendance), and complete an evaluation form.There is no commercial support or interest associated with the activity. There is no joint providership.Children’s of Alabama is approved by the Alabama Board of Nursing as a Provider of Continuing Education in Nursing: ABNP0113 Expiration: 06/29/2021The Children’s Hospital of Alabama/Children’s of Alabama is approved as a provider of nursing continuing professional development by The Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.Provider Number 5-173; Expires 02/01/2022The speaker has nothing to disclose.Checklist of Items to Be SubmittedThis page does not have to be included with the applicationActivity ApplicationTest/ Return Demonstration Checklist, if applicableEvaluation if not using COA Sing Event Single Presenter EvaluationAttendance Verification form not using COA formPlanning Table, including referencesAgenda for activities ≥ 3Hours including breaks & lunchBiographical Date Form – must be submitted yearly, Current list of received forms located on Nursing Professional Development websiteConflict of Interest Forms – must have form for each planner & speakerDisclosure Statement(s)External /Out of Hospital Advertisement, if applicableCommercial Support Agreement, if applicable ................
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