Educational Activity Application, Page 11
Georgia Nurses Association Continuing Education Review Committee3032 Briarcliff Road NE, Atlanta, GA 30329-2655
www.georgianurses.org •
Educational Activity Application
DIRECTIONS: All information must be completed in this format. The step-by-step explanation for completion of the application is provided in the “Criteria For Educational Activities” located at www.georgianurses.org/ce_approval.htm. Please review this information before completing the application.
· For activities of 5 contact hours or more, submit 3 complete, typed, collated copies of the entire application, all attachments and payment to the address above. Page numbers must be used.
· For activities of less than 5 contact hours, you may email the application and all attachments to: . Payment must be received before application can be processed.
Section I DEMOGRAPHIC DATA
Title of Activity:
Organization Applying for Approval:
Contact Hours Requested: ______
Note: For multi-focus activities, contact hours will be different from clock hours listed above.
Activity Type:
______Provider-directed, provider-paced: Live presentation (in person or webinar)
· Presentation Date: ______
· Presentation Location: ______
______Provider-directed, learner-paced: Enduring material (online modules, workbooks, archived webinars etc)
· Planned start date of enduring material: ______
· Planned expiration/end date of enduring material: ______
If approved, will this activity be presented more than once during the approval period? YES_____NO______
Has your organization been previously denied approval of an application for Continuing Nursing Education?
· ______No ______Yes
· If Yes, contact GNA to discuss previous denial before completing and submitting application.
______
Section II: HUMAN RESOURCES
Contact Person. Provide the following information for the contact person for this activity. NOTE: If this person is also on the planning committee, be sure to include his/her name in the Planning Committee list and provide biographical data form.
Name & Credentials:
Address:
Daytime Phone Number: Ext: Fax Number:
*E-Mail (preferred method of contact):
Section III: Educational Design
Key Element 1: Assessment of Learner Needs
A. Identify the target audience:
All RNs Advance Practice RNs RN, Specialty:
LPNs Other - (Describe):
B. Type of needs assessment method used to plan this event? (Check all that apply)
Surveying stakeholders, target audience members, subject matter experts or similar
Requesting input from stakeholders such as learners, managers, or subject matter experts
Reviewing quality studies and/or performance improvement a to identify opportunities for improvement
Reviewing evaluations of previous educational activities
Reviewing trends in literature, law and health care
Other - Describe:
C. Indicate source of supporting evidence for needs assessment data.
(Check all that apply. Individual Activity Applicant must be able to access this data upon request.)
Annual employee survey
Literature Review
Outcome Data
Surveys results from stakeholders or learners
Quality Data
Requests (e.g., via phone, in person or by email)
Written evaluation summary requests
Other - Describe:
Needs assessment data are attached or available upon request.
(e.g., survey data, reference in literature, QI data, etc.)
D. Identify the appropriate gap for the intended target audience that this educational activity will address.
Educational Activity Application, Page 11
Gap in Knowledge (knows)
Gap in Skills (knows how)
Gap in Practice (shows/does)
Other - Describe:
Educational Activity Application, Page 11
______
Key Element 2: Qualified Planners and Faculty.
The Planning Committee must include 1 designated Nurse Planner (RN with a minimum of a baccalaureate degree in nursing) and at least one other member. The designated nurse planner is responsible for adhering to all accreditation criteria, has knowledge of the CE process, and must be actively involved in all planning, implementation, and evaluation of the activity. One member of the planning committee must have appropriate subject matter expertise for the activity.
A. Nurse Planner:
1. Nurse Planner (Name and Degrees):
2. Explain how the nurse planner has knowledge of current CE process/criteria (attends
conferences, part of current job role, trained by lead nurse planner, committee meetings,
etc):
3. Nurse Planner was involved in all planning and analysis of evaluation data: [ ] initial
B. Planning Committee:
1. Complete the table below for each person on the planning committee (including the nurse planner) and include name, educational degree(s), credentials, and role on the planning committee. Identified roles include, but are not limited to: nurse planner, planner, subject matter expert, reviewer or other (If you identify a committee member with “other” role, please provide explanation of this role below the table).
Committee Member Name / Credentials / Degrees / Role on Committee2. ______Bio form including conflict of interest/conflict resolution for each planning committee member is attached.
3. ______All bio forms have been reviewed for potential conflict of interest; any resolution required is addressed.
C. Faculty/Presenters/Authors:
1. Faculty/Presenters/Authors must have documented qualifications that demonstrate their education and/or experience in the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. Faculty/Presenters/Authors do not have to be nurses, but nurses should address nursing care and nursing implications, as applicable.
Faculty/Presenter/Author Name / Credentials / Degrees2. Describe how the needed qualifications of Faculty/Presenters/Authors are identified: (Check all that apply).
Content expertise
Demonstrated comfort with teaching methodology (e.g., web-based, etc.)
Presentation skills
Familiarity with target audience
Other -Describe:
3. Planning committee assures the qualifications of the Faculty/Presenters/Authors are appropriate and adequate by: (Check all that apply)
Review of resume/CV of faculty/presenter/author.
Recommendation by colleagues.
Review of literature written by faculty/presenter/author.
Observation of previous presentation by faculty/presenter/author.
New faculty/presenter/author being mentored by:
Other - Describe:
4. ______Bio form including conflict of interest/conflict resolution for each planning committee member is attached.
5. ______All bio forms have been reviewed for potential conflict of interest; any resolution required is addressed.
______
Key Element 3: Effective Design Principles
New Information: ANCC contact hours may now be awarded for certain in-service or staff development activities, including BLS and repeat offerings of activities such as PALS, ACLS, NRP or similar activities. For more information, please see explanations provided in CNE APPLICATION PROCESS AND FEE SCHEDULE, provided on the GNA website.
Use the Educational Planning Table(s) provided in this application to document Items C, D1, E, and F for a minimum of three hours of the educational activity to be provided. Items A, B, D2, G, H1, H2, I1, I2, and J should be answered in the space provided in this portion of the application.
A. Identified Gaps: Which of the following gaps have identified the need for this activity?
_____Gap in Knowledge (knows) _____Gap in Skills (knows how)
_____Gap in Practice (shows/does) _____Other (if other, provide description):______
______
B. Purpose (Stated in relation to the outcome desired of the learner at the conclusion of the activity)
C. Educational Objectives: Specificobjectives for the learning activityare developed collaboratively by the planners and Faculty/Planners/Authors (if applicable) andmust relate to the purpose of the activity. Each objective should have one measureable action verb andshould specify what the learner willknow and/ordo once the objective has been completed (the outcome of attaining the objective).
D. Quality of Content: List the content for each objective on the Educational Planning Table.
1. Content must:
· Be congruent with purpose and objectives
· Include details beyond a restatement of objectives
· Be numbered consistently with the related objective
· Be evidence-based or based on the best available evidence
2. Content for this educational activity is current (past 5-7 years) and was chosen from:
· Information available from the following organization/web site:______
· Information available through peer-reviewed journal/resource: ______
· Clinical guidelines (specify): ______
· Expert resource (specify):______
· Textbook reference: ______
· Other: ______
E. Time Frame: For live presentations only: List time frame for the activity/session, giving both the clock time and the number of minutes to be counted for contact hours, i.e. 8:30 – 9:30 a.m., 60 contact minutes.
F. Teaching-Learning Strategies: List the methods and instructional strategies to be used by Faculty/Presenters/Authors to cover each objective on the Educational Planning Table. Teaching /learning strategies must be congruent with objectives and content.
G. Learner Feedback: Check the best description or describe how learners will be provided feedback.
Question and answers during activity.
Return results of testing.
Return demonstration
Role play
Follow-up Communication
____ Other - Describe:
H. Successful Completion: (Consistent with the purpose, objectives and teaching and learning strategies)
1. Criteria for successful completion for live and enduring material/web-based activities include: (Check all that apply)
Attendance at entire event or session
Attendance for at least ____% of event
Attendance at 1 or more sessions
Completion/submission of evaluation form (required)
Achieving passing score on post-test. (Passing score is: ____%)
Return demonstration
Other - Describe:
2. Rationale for method selected above to determine successful completion: (Check all that apply)
Method of evaluation selected
Importance of content knowledge
Importance of content application
Required by employer or organization
Other - Describe:
I. Awarding Contact Hours: A contact hour is a 60 minute hour. The contact hour may be taken to the tenths or the hundredths; but may not be rounded up. (e.g. 2.758 should be 2.75 or 2.7, not 2.8)
1. Live Events: Calculate the number of contact hours based on the educational minutes, including actual presentation, pre/post tests, clinical experience (i.e., return demonstrations, etc.) and evaluations. Time spent in welcome, introductions, and breaks may not be counted for contact hours. NOTE: If you are providing educational planning forms for 3 hours of longer activity, provide a detailed agenda of entire activity to allow verification of contact hour request.
Actual Minutes = ______; Divided by 60 = ______contact hours requested.
2. Enduring materials (print, CD, web-based, etc.): What was the method for calculating the contact hours? (Select one)
Pilot Study
Historical Data
Complexity of content and data
Other - Describe:
3. For enduring materials, provide supportive documentation of the rationale used to determine the number of contact hours to be awarded. (attach on separate sheet, providing page number here______).
J. Verify Participation
Attendance/participation will be verified through sign in sheets/registration form.
Signed attestation statement by participant verifying completion
Collection of participation verification via computer log
Other - Describe:
______
Key Element 4: Activity Evaluation
A. [ ] Submit a copy of the evaluation tool(s) to be used for this event. Evaluation must allow learners to evaluate achievement of each objective, as stated on educational planning form, and effectiveness of each presenter, including all panel members. A sample evaluation form is provided in the GNA Appendices.
B. Check or describe the method to be used to evaluate the activity (check all that apply):
[ ] Evaluation Form (required.)
[ ] Pre and/or Post test (Attach a copy if testing to be used )
[ ] Return Demonstration
[ ] Case Study Analysis
[ ] Role play
[ ] Longitudinal study with self-reported change in practice (long term method)
[ ] Data collection related to quality outcome measure (long term method)
[ ] Observation of performance in practice (long term method)
[ ] Other - Describe:
C. Nurse Planner will ensure that a summative evaluation will be prepared upon completion of activity: (Nurse planner to initial):______
D. Check the best description or describe how the evaluation data will be used:
[ ] Refine future presentations of this course.
[ ] Create new programs.
[ ] Discontinue the activity.
[ ] Decide whether or not to change this faculty or facility.
[ ] Other - Describe:
______
Key Element 5: Accreditation Statements
The Commission on Accreditation has revised the requirements for use of the ANCC accreditation statement. It is no longer necessary to use the accreditation statements on all communications and marketing materials. It is now required that you provide the accreditation statement to learners: 1) before the start of every educational activity, and 2) on each certificate of completion.
The approval statement must be displayed clearly to the learner, stand alone on its own line of text, and be written exactly as provided below. When referring to contact hours, the term "accredited contact hours" should never be used. An organization is accredited or approved; contact hours are awarded.
This continuing nursing education activity was approved by the Georgia Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission On Accreditation.
______
Key Element 6: Documentation of Completion. Written verification of successful completion of activity.
· Learners must receive documentation of successful completion of the educational activity
· Document/certificate must include:
o Name and address of the provider of the educational activity (web address acceptable)
o Title and date of completion of educational activity
o Number of contact hours awarded
o Space for name of learner
Official approval statement (must stand alone on the document, and may not be modified in any way):
This continuing nursing education activity was approved by the Georgia Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission On Accreditation.
[ ] A completed sample of the certificate is included.
______
Key Element 7: Sponsorship and Commercialism.
· A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on , patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients. Exceptions are made for non-profit or government organizations and non-health care related companies.
· Commercial Support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity.
· A sponsor is identified as an organization that does not meet the definition of commercial interest. Sponsorship is financial, or in-kind, contributions given by an entity that is not a commercial interest, which is used to pay all or part of the costs of a CNE activity.
If no commercial support or sponsorship received, select A below.