Alabamanurses.org



Alabama State Nurses Association

NURSE PEER REVIEWER FORM

Individual Activity ~ Review of Activity Application

Activity #: ________________ Activity Name:

Type of activity:

⇨ Provider Directed, Provider Paced

⇨ Provider Directed, Learner Paced, Enduring Material

⇨ Blended Activity

Evaluation of conflict of interest

As the Nurse Peer Reviewer for this Individual Activity Applicant, I attest to having no conflict of interest with this applicant that would

preclude me from reviewing this application in a fair and unbiased manner:

⇨ Yes

⇨ No (Notify ASNA Office)

Signature/Credentials: Date of Review: _____________________

|Activity file documentation criterion |Nurse Peer Reviewer |Additional documents |Comments: | |

| |Evaluation |requested: (list) | |Reconciliation |

|Description of professional practice gap |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|1. Description of |Met | | | |

|current state |Partially met | | | |

|2. Description of |Not met | | | |

|desired achievable state |N/A t | | | |

|3. Identified gap | | | | |

|Evidence to validate |Met | | | |

|practice gap |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Summary of data gathered |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Educational need that underlies gap |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Target audience |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Desired learning outcomes |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Area impact noted |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Outcome Measure |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Activity file documentation criterion |Nurse Peer Reviewer |Additional documents |Comments: | |

| |Evaluation |requested: (list) | |Reconciliation |

|Supporting |Met | | | |

|resources/references for content of the |Partially met | | | |

|activity |Not met | | | |

| |N/A | | | |

|Learner engagement strategies |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Criteria for awarding |Met | | | |

|contact hours & contact hours including |Partially met | | | |

|calculation |Not met | | | |

|method |N/A | | | |

|Description of evaluation method |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Short term evaluation |Met | | | |

|options |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Long term evaluation options |Met | | | |

| |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

| Attachment 1: |Met | | | |

|Education Planning Table |Partially met | | | |

| |Not met | | | |

| |N/A | | | |

|Attachment 2: |Met | | | |

|Table of individuals in position to control |Partially met | | | |

|content |Not met | | | |

| |N/A | | | |

| Attachment 3: |Met | | | |

|COI all individuals’ in |Partially met | | | |

|position to control |Not met | | | |

|content |N/A | | | |

| Attachment 4: |Met | | | |

|Bio/COI Nurse |Partially met | | | |

|Planner(s) & content |Not met | | | |

|experts |N/A | | | |

|Attachment 5: |Met | | | |

|Agenda if activity |Partially met | | | |

|longer than 3 hours |Not met | | | |

| |N/A | | | |

| Attachment 6: |Met | | | |

|Certificate of |Partially met | | | |

|attendance/completion |Not met | | | |

| |N/A | | | |

| |Nurse Peer Reviewer | | | |

|Activity file documentation criterion |Evaluation |Additional documents |Comments: |Reconciliation |

| | |requested: (list) | | |

| Attachment 7: |Met | | | |

|Commercial Support |Partially met | | | |

|Agreement |Not met | | | |

| |N/A | | | |

| Attachment 8: |Met | | | |

|Required Disclosure |Partially met | | | |

|Information |Not met | | | |

| |N/A | | | |

| Attachment 9: |Met | | | |

|Summative Evaluation |Partially met | | | |

|if used |Not met | | | |

| |N/A | | | |

|Attachment 10: |Met | | | |

|Copy of Marketing |Partially met | | | |

|Materials |Not met | | | |

| |N/A | | | |

Additional Comments: (Option

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download