Eligibility and Attestation Form
Section 1: Demographic Information
Organizations must meet all eligibility requirements and submit the application according to the DNA Approval Program timeline and submission requirements. Applications received from organizations that do not meet the eligibility requirements will be rejected without substantive review. Applicant organizations must be adhering to the most current DNA Approved Providers Policies and Operations Manual.
Name of Applicant: Click or tap here to enter text.
Web Address: Click or tap here to enter text.
Street Address: Click or tap here to enter text.
City: Click or tap here to enter text. State: Click or tap here to enter text. Zip Code: Click or tap here to enter text.
If applicant is part of a larger organization, provide name of organization: Click or tap here to enter text.
Primary Nurse Planner(Name and Credentials): Click or tap here to enter text.
Telephone Number: Click or tap here to enter text. Email Address: Click or tap here to enter text.
Name as it appears on RN License:Click or tap here to enter text.
RN License Number: Click or tap here to enter text. State of Issue:Click or tap here to enter text.
Additional Point of Contact(Name and Credentials): Click or tap here to enter text.
Title/Position: Click or tap here to enter text.
Telephone Number: Click or tap here to enter text. Email Address: Click or tap here to enter text.
Section 2: Eligibility Verification
Primary Nurse Planner is licensed registered nurse with a baccalaureate or higher in nursing? ☐Yes ☐ No
Is the applicant currently or has the applicant previously been an approved provider through an ANCC Accredited Approver?
☐Yes ☐ No
Has the applicant ever been denied approval, or had an approval suspended or revoked? ☐Yes ☐ No
Is the applicant currently or has the applicant previously been approved by Delaware Nurses Association? ☐Yes ☐ No
Does the applicant target the majority (>50%) of their CNE activities to nurses in a single HHS region and its contiguous states
(based on the HHS regions: about/agencies/regional-offices).☐Yes ☐ No
Applicants whose target audience is in multiple regions or in states that are not confined to a single region and its contiguous states for more than 50% of its activities may not be Approved Providers. Instead, they must apply to ANCC as an Accredited Providers through the accreditation process.
Check type of organization of the Provider Unit:
☐ANA organizational affiliate
☐College or university
☐ Constituent and State Nurses Association (C/SNA) of the ANA
☐Federal Nursing Service (FNS)
☐Health care facility
☐Health-related organization
☐ Multidisciplinary educational group
☐ Professional nursing education group
☐ Specialty nursing organization (SNO)
☐ National nursing association/organization
The applicant does NOT meet the definition of a commercial interest.
- Does not produce, market, resell, or distribute healthcare goods or services consumed by or used on patients
- Is not owned by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by
or used on patients.
Exceptions are made for nonprofit or government organizations and non-healthcare related companies.
☐ My organization does NOT meet the definition of a commercial interest organization.
The applicant has the structure to administratively and operationally be responsible for coordinating the entire process of
- planning, implementing, and evaluating CNE activities in compliance with DNA Approval Program criteria;
- have the infrastructure in place to operate as an Approved Provider;
- be in compliance with all applicable federal, state, and local laws and regulations that affect the Approved Provider’s ability to meet the DNA Approval Program criteria; and
- be operational for a minimum of six months prior to application.
☐ My organization has the structure to administer and operationally support a Provider Unit.
☐ My organization is in compliance with all applicable federal, state, and local laws and regulations.
☐ My organization has been operational for at least six months prior to applying for Approved Provider status.
The applicant has a Primary Nurse Planner who
•is a registered nurse with a current, unencumbered nursing license and holds a baccalaureate degree or higher in nursing;
•has authority within the organization to ensure compliance with the DNA Approval criteria and Approver Unit requirements in the provision of CNE;
•is responsible for the orientation of all Nurse Planners in the organization to the DNA Approval Program criteria and Approver Unit requirements;
•ensures each Nurse Planner is a registered nurse and holds a current, unencumbered nursing license and a baccalaureate degree or higher in nursing;
•ensure that each CNE activity has a qualified Nurse Planner who is an active participant in the planning, implementation, and evaluation process; and
•serves as the liaison between the Delaware Nurses Association and the Approved Provider.
☐ Yes☐ No
New Approved Providers
Applicant has assessed, planned, implemented, and evaluated:
- at least three separate educational activities provided at separate and distinct events;☐ Yes ☐ No
- with the direct involvement of a Nurse Planner;☐ Yes ☐ No
- that adhere to the DNA Approval Program criteria;☐ Yes ☐ No
- each learning activity which is at least 1 hour (60 minutes) in length;☐ Yes ☐ No
- each learning activity were NOT joint provided with another organization. ☐ Yes ☐ No
New Approved Providers must plan, implement, and evaluate individual educational activities without a joint provider to demonstrate understanding and adherence to the DNA Approval Program criteria.
Section 3: Statement of Understanding
I attest, by my signature below, that I am duly authorized by Click or tap here to enter text. to submit this application for Approved Provider offered by the Delaware Nurses Association and to make the statements herein.
On behalf of Click or tap here to enter text., I have read the Approved Provider eligibility requirements and criteria. I understand that Click or tap here to enter text. is subject to all eligibility requirements and criteria for approval as described in the current DNA Approved Providers Polices and Application Manual and any updates thereto. I understand that approval depends on successfully meeting eligibility requirements and Approved Provider criteria and that continued approval is dependent upon continued compliance.
On behalf of Click or tap here to enter text., by my signature below, I authorize Delaware Nurses Association Continuing Education Committee to make whatever inquiries and investigations that they, in their sole discretion, deem necessary to obtain or verify information submitted with or necessary for review of this application.
On behalf of Click or tap here to enter text., I expressly acknowledge and agree that information accumulated by the Delaware Nurses Association through the approval process may use demographics and outcome datadescribing characteristics of individual applicants anonymously and in the aggregate and analyze trends or address other CE Committee-defined or approved research questions. All data received by the Delaware Nurses Association will be remain confidential and will be reported only in aggregate form unless Click or tap here to enter text. grants permission to share data specific to Click or tap here to enter text..
On behalf of Click or tap here to enter text., I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of Click or tap here to enter text., that Click or tap here to enter text. will comply with all eligibility requirements and the DNA Approval Program criteria throughout the entire approval period, including all reapplication periods for maintaining approval, and that Click or tap here to enter text. will notify the Delaware Nurses Association promptly if, for any reason while this application is pending or during any approval period, Click or tap here to enter text.does not maintain compliance. I understand that any misstatement ofmaterial fact submitted on, with or in furtherance of this application for approval shall be sufficient cause for the Delaware Nurses Association to deny,suspend or terminate Approved Provider status for Click or tap here to enter text. and to take other appropriate action against Click or tap here to enter text..
An “X” in the box below serves as the electronic signature of the individual completing this Eligibility and Attestation Form and attests to the accuracy of the information contained.
Electronic Signature Required Date Click or tap here to enter text.
Completed By (Name and Title): Click or tap here to enter text.
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