WISCONSIN NURSES ASSOCIATION
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Biographical Data Form
|Provider Organization: | |
|Title of Activity: | |
|Date(s), if live: | |
|Individual’s role(s) in this Educational Activity: (check ALL that apply) |
| |Presenter/Author | |Planning Committee Member |
| |Content Expert (Subject Matter Expert) | |CNE Nurse Planner responsible for this activity |
| |Content Reviewer | |Primary Nurse Planner (Approved Providers only) |
| |Other faculty in control of content (describe): | |
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|Name and Credentials: | |
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|Current Position/Title: | |
|Mailing Address: | |
|Phone: | |
|Email: | |
Your educational preparation: (include basic through highest degree held)
|Degree |Major Area of Study |Institution – Name, City, State |
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|1. |ALL PRESENTERS/AUTHORS/CONTENT REVIEWERS/FACULTY/PLANNERS/NURSE PLANNERS: |
| |Describe your relevant professional experience, continuing education, or other information that qualifies you for your role as a presenter, |
| |developer, reviewer, or planner of educational content: |
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|2. |ALL PRESENTERS/AUTHORS/CONTENT REVIEWERS/FACULTY/ PLANNERS/NURSE PLANNERS with subject matter expertise: |
| |Describe your relevant professional experience, continuing education, or other information that qualifies you as a subject matter expert: |
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|3. |Complete this section if you are a NURSE PLANNER for the ORGANIZATION RESPONSIBLE FOR AN EDUCATIONAL ACTIVITY OR if you are a PRIMARY NURSE PLANNER |
| |of a WNA CEAP APPROVED PROVIDER UNIT: |
|A |Describe how you were oriented to, or have current knowledge of, the 2015 ANCC/WNA CEAP criteria for planning, implementing and evaluating |
| |continuing nursing education (CNE) activities: |
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|B |Describe your experience related to the functions of your role either as a Nurse Planner for this activity or Primary Nurse Planner of a WNA CEAP |
| |Approved Provider Unit: |
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|PRIMARY NURSE PLANNERS of APPROVED PROVIDER UNITS only: |
|C |Licensure as a Registered Nurse: (must be current) |
|RN License Number: | |State: | |Expiration (month/year): | | |
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