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
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