Instructions:

1. Submit ONE COPY AND PAYMENT TO THE NURSE PRACTITIONER ASSOCIATION New York State (The NPA) OFFICE AND ONE COPY TO THE QUALITY OVERSIGHT AND CLINICAL REVIEW CHAIRPERSON. The application must be received four weeks prior to the program. All final documentation must be received two weeks prior to the program for review (i.e activity documentation, bibliography, etc.). (Handwritten applications will not be considered). All applications must include:

a. The completed application face sheet

b. An outline of objectives, topics, teaching and strategies (outline format supplied in this packet)

c. A signed copy of the responsibility for records form (included in packet)

d. A copy of the Evaluation Tool

e. A copy of the Certificate to be awarded to the participant

f. A biographical data sheet (supplied in this packet)

g. A bibliography

2. Applicants seeking approval for multi-day conferences must submit all of the program offerings.

3. One (1) contact hour is equal to 60 minutes of lecture, discussion, evaluation or test taking time. Business meeting time, refreshments and breaks are not to be included in the calculation for contact hours.

4. The fee is non-refundable and prepayment is required. This fee schedule is per program. The fee schedule is as follows:

A. 1 - 8 contact hours $50.00

B. 9 - 16 contact hours 60.00

C. 17 - 29 contact hours 70.00

D. over 30 contact hours: 100.00

5. Renewals are permitted. Programs eligible for renewal include those programs, which will be offered in the year following initial approval. The program to be renewed must be offered exactly as it was originally approved. The fee for a renewal is $50.00. Documents required for renewals are:

A. Application face sheet

B. Up-dated bibliography

C. A signed copy of the responsibility for records form (included in packet)

6.Upon approval of the program The NPA will issue a program code. This code must appear on the attendance certificates and is to be used for all correspondence concerning the program.

THE NURSE PRACTITIONER ASSOCIATION

NEW YORK STATE

EDUCATIONAL ACTIVITY PRIVATE ED I and II APPLICATION

An offering is a single educational activity that may be presented once or repeated. THE APPROVALPERIOD FOR ANOFFERING IS ONE YEAR. The retroactive granting of continuing education units is prohibited.

NOTE: Applications must be submitted at least four (4) weeks prior to the first date of presentation of the first offering.

SUBMIT ONE (1) COPY OF THE APPLICATION AND ALL ATTACHMENTS TO THE QUALITY OVERSIGHT AND CLINICAL REVIEW CHAIR AND ONE (1) COPY TO THE NURSE PRACTITIONER ASSOCIATION OFFICE. MAINTAIN THE MASTER COPY OF ALL SUBMISSIONS FOR YOUR RECORDS.

Title of CE Activity: ______

Date ______Time ______Location of the CE Activity______

Expected Number of Participants: ______

Official Name of the Organization/Facility/ Agency/Individual Providing the Activity:
______

Address: ______

City: ______State: ______Zip: ______

Number of Contact Hours: ______Application fee enclosed $ ______

Is Applicant a member of The Nurse Practitioner Association? ______Yes ______No

Name And Title Of Individual To Contact Regarding This Application

A.Human Resources

1.Person Administratively Responsible: Provide the following information for the person responsible for administering this activity.

Name & Credentials: ______Title: ______

Address: (This address will be used for all mailings)

______

______Daytime Phone Number: ______Ext: ______

Fax Number: ______E-Mail: ______

Declaration of Responsibility for Record Keeping

A record keeping system must be established for this offering. For a period of six years you are required to maintain the following essential material:

  • A complete copy of the offering application and all supporting documentation.
  • A copy of the certificate(s) awarded to participants.
  • A summary of participant evaluations.
  • Names and addresses of participants and number of contact hours awarded to each.
  • The approval letter from the Nurse Practitioner Association indicating the code number and contact hour award.

Please indicate your commitment to maintain the above stated records by signing

below.

I, (name of responsibility party) representing ______(name of organization) attest to the fact that a system exists for storage of records that allows for retrieval of essential information and is available only to authorized individuals.

CONTACT HOURS Fact Sheet

Educational Objectives:

An educational objective is a statement of what behavior the faculty member expects to occur as a result of the teaching that has taken place. Objectives are written in measurable, behavioral terms. One educational objective is required for each major topic included in the topical outline. The evaluation of the program is based on the educational objectives, that is, the learners must evaluate each objective.

Examples:

At the end of this offering, the learner will be able to:

1. Differentiate between various types of cholesterol

2. Discuss the interaction between hypercholesterolemia and other cardiac risk factors

3. Evaluate pharmacologic treatment modalities used in the treatment of hypercholesterolemia.

4. Identify appropriate treatment modalities for patients with hypercholesterolemia.

Topical Outline:

The topical outline is an overview of the content to be presented. Content should be divided into major and minor headings. Each major heading in the topical outline requires an educational objective

Examples:

I The Importance of Cholesterol as a Cardiac Risk Factor

A. Definition of cholesterol

B. Cardiac risk factors

C. Types of cholesterol

II Treatment for Hyperlipidemia

A. Life style modification

B. Diet

C. Drug therapy

Teaching Strategies:

Teaching strategies refer to the way in which the faculty will deliver the information to be learned. There are a multitude of excellent teaching strategies.

Examples:

Lecture

Role play

Group discussion

Computer assisted instruction

Use of media

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ACTIVITY DOCUMENTATION FORM

Title of Presentation:

OBJECTIVES / CONTENT (Topics) / TIME FRAME / PRESENTER / METHODS
List all learner’s objectives in behavioral terms / Provide an outline of the content for each objective. It must be more than a restatement of the objective. / State the time frame for each objective / List the presenter for each objective. / Describe the teaching methods, strategies, materials & resources for each objective

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BIOGRAPHICAL DATA FORM

This individual is: (Check all that apply) Administratively Responsible Person Planning Committee Member Presenter/Content Specialist

Instructions: Make as many copies of this form as necessary to provide the required information documenting adherence to the criteria. Do not send curriculum vitae. Form must be typed or word-processed.

Name, degree, and credentials:

Home Address or Business Address:

Day Telephone: Extension: E-mail address:

Present position (title):

Employer:

Educational Activity Planners: Describe your professional qualifications and familiarity with the target audience

Educational Activity Faculty/Content Specialist: Describe your knowledge and expertise in this topic area

Conflict of Interest Disclosure

Having an interest in an organization does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved. In order to ensure balance, independence, objectivity, and scientific rigor at all programs, the planers and faculty must take full disclosure indicating whether the planner, faculty, or content specialist and/or his/her immediate family members have an relationships with sources of commercial support, e.g. pharmaceutical companies, biomedical device manufacturers and/or corporations whose products or services are related to pertinent therapeutic areas. All planners, faculty and content specialists participating in CE activities must disclose to the audience any

A. Relationship with companies who manufacture products used in the treatment of the subjects under discussion

B. Relationship between the planner, faculty, or content specialist and commercial supporter(s) of the activity and/or

C. Intent to discuss unlabeled uses of a commercial product, or an investigational; use of a product not yet approved for this purpose.

All information disclosed must be shared with the audience either on the program handouts, advertising and/or audiovisual presentation.

A.Is there a relationship with companies who manufacture products used in the treatment of the subjects under discussion:

YesNo If yes, list company(ies) with relationship:

RelationshipName of Commercial Company(ies)

Research Support

Speaker’s Bureau

Consultant

Shareholder

Other Support

Large Gift(s)

B.Is there a discussion of unlabeled uses?

If yes, you must disclose this information during your presentation. How will you do this?

1. Verbal statement during the presentation

2. Information provided on handouts

3. Information provided in audiovisuals

4. Other, please describe

C.How will any conflict of interest be resolved?

___ 1. Have discussed this conflict with individual who is now aware of and agrees to our policy.

___ 2. Presenter has signed a statement that says s/he will present information fairly and without bias.

___ 3. RN with minimum of BSN or designee will monitor session to ensure conflict does not arise.

___ 4. Not applicable since no conflict of interest.

___ 5. Other: Describe:

All information disclosed must be shared with the audience whether on the program handouts, advertising, and/or audiovisual presentation.

Signature: Date :

By checking this box, I am providing my electronic signature approving all the information entered above. (Please enter name and date on signature and date lines above).

Check List

*NOTE: The individual (planner) submitting the application is responsible for submitting all materials in the required format. In some cases this may mean that the individual (planner) will have to complete the forms if the presenter does not.

______Verification of payment

______Completed Educational Activity Application

______Activity Documentation Form (for each presentation)

______A signed copy of the responsibility for records form

______A copy of the evaluation tool

______A copy of the Certificate to be awarded to the participant

______Biographical data/disclosure forms for each presenter

______Check enclosed or payment arrangements have been made with the NPA

Send check and one copy to: information must be received by The NPA in order to receive approval for the program

The Nurse Practitioner Association

New York State

12 Corporate Drive

Clifton Park, NY 12065

Office: 518-348-0719

Fax: 518-348-0720

Send one copy to:

Dr. Geraldine Abbatiello

Email:

12 Sheridan Drive

PawlingNY12564

Work: 917-299-0256

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SAMPLE ACTIVITY DOCUMENTATION FORM

Title of Presentation: Humor in the Workplace

OBJECTIVES / CONTENT (Topics) / TIME FRAME / PRESENTER / METHODS
List all learner’s objectives in behavioral terms / Provide an outline of the content for each objective. It must be more than a restatement of the objective. / State the time frame for each objective / List the presenter for each objective. / Describe the teaching methods, strategies, materials & resources for each objective
1. Identify 3 uses of humor to help reduce stress / I. Concept of humor
A. What it is, what it isn’t
B. Effect of humor in stress reduction
C. Examples of types of humor
D. Humor: what, when and where
E. The culture of humor / 30 Minutes / Presenter XYZ
Entire session / Lecture
Demonstration
Interactive process entire session
2. Recognize 3 advantages of humor in the work place / II. Uses of humor in the work place
A. Examples
B. Advantages
C. Methods / 30 minutes
3. Identify 3 disadvantages of humor in the work place / III. Disadvantages of humor in the work place
A. Cultural insensitivity
B. Poor timing
C. Work place expectations / 30 minutes

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SPEAKER EVALUATION FORM

Title of Presentation

Speaker Name

Please complete this evaluation form by using the scale to rate the following:

4 = Agree3 = Somewhat Agree 2 = Disagree Somewhat 1 = Disagree

(insert objectives)

1. To what extent did the presenter address each objective? (each object must be listed)

1. 4321

2.4321

3.4321

4.4321

2. To what extent was the speaker for this session

knowledgeable, organized and effective in their

presentation? 4321

3. Were the speakers teaching methods and aids used

appropriately and effectively?4321

4. Did the presentation meet your expectations?YesNo

5. Was the information and/or data current?YesNo

6. Was the information and/or data accurate?YesNo

If no please explain:

Other comments or suggestions:

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