Individual Activity Application
Maryland Nurses Association
Individual Educational Activity Application
2015 Criteria
Applicants interested in submitting an individual educational activity for approval must complete:
☐ Individual Activity Applicant Eligibility Verification Form,
☐ Individual Activity Applicant Eligibility Commercial Interest Addendum (if applicable),
☐ This form - Individual Educational Activity Application
Organization Name:
Is this continuing education? Is this learning activity intended to build upon the educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to improve the health of the public and RNs’ pursuit of their professional career goals?
☐ Yes ☐ No If no, the activity is not eligible for approval.
Title of Activity: Click here to enter text.
Number of contact hours being requesting for approval:
Date Form Completed: Click here to enter a date.
Activity Type:
☐Provider-directed, provider-paced: Live (in person or webinar)
· Date(s) of live activity:
☐Provider-directed, learner-paced: Enduring material
· Start date of enduring material:
· Expiration/end date of enduring material: Click here to enter a date.
☐Blended activity
· Date(s) of enduring materials (e.g. prework): Click here to enter a date.
· Date of live portion of activity: Click here to enter a date.
Nurse Planner contact information for this activity.
Name and credentials:
Email Address:
A.
Description of the professional practice gap (e.g. change in practice, problem in practice, opportunity for improvement)
Describe the current state:
Describe the desired state:
Identified gap:
B. Evidence to validate the professional practice gap (check all methods/types of data that apply)
Individual Activity Application Form Template 10.01.15
Individual Activity Application
☐ Survey data from stakeholders, target audience members, subject matter experts or similar
☐ Input from stakeholders such as learners, managers, or subject matter experts
☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement
☐ Evaluation data from previous education activities
☐ Trends in literature, law and health care
☐ Direct observation
☐ Other—Describe:
Please provide a brief summary of data gathered that validates the need for this activity:
Educational need that underlies the professional practice gap (e.g. knowledge, skill and/or practices)
Choose an item
C. Description of the target audience. (You can select more than one target audience).
1. Choose an item.
2. Choose an item.
3. Choose an item.
4. Choose an item.
D. Desired learning outcome(s) (What will the outcome be as a result of participation in this activity?)
Area of impact (check all that apply):
☐ Nursing Professional Development ☐Patient Outcome
☐ Other- Describe:
E. Outcome Measure(s) (A quantitative statement as to how the outcome will be measured):
Content of activity: A description of the content with supporting references or resources
☐ See Educational Planning Table OR
☐ Describe content and include time calculation for content: Click here to enter text.
Content for this educational activity was chosen from:
☐ Information available from the following organization/web site (organization/web site must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content; examples – Agency for Healthcare Research and Quality, Centers for Disease Control, National Institutes of Health):
☐ Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years):
☐ Clinical guidelines (example - www.guidelines.gov):
☐ Expert resource (individual, organization, educational institution) (book, article, web site):
☐ Textbook reference:
☐ Other:
F. Learner engagement strategies
☐ See Educational Planning Table OR
☐ Integrating opportunities for dialogue or question/answer
☐ Including time for self-check or reflection
☐ Analyzing case studies
☐ Providing opportunities for problem-based learning
☐ Other:
G. Criteria for Awarding Contact Hours
Criteria for awarding contact hours for live and enduring material activities include:
(Check all that apply)
☐ Attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10 minutes of activity)
☐ Credit awarded commensurate with participation
☐ Attendance at 1 or more sessions
☐ Completion/submission of evaluation form
☐ Successful completion of a post-test (e.g., attendee must score % or higher)
☐ Successful completion of a return demonstration
☐ Other - Describe:
H. Description of evaluation method: Evidence that change in knowledge, skills and/or practices of target audience was assessed
I. Short-term evaluation options:
☐ Intent to change practice
☐ Active participation in learning activity
☐ Post-test
☐ Return demonstration
☐ Case study analysis
☐ Role-play
☐ Other – Describe:
Long-term evaluation options:
☐ Self-reported change in practice
☐ Change in quality outcome measure
☐ Return on Investment (ROI)
☐ Observation of performance
☐ Other – Describe:
Attachment1
Individuals in a Position to Control Content
Complete the table below for each person in a position to control content of the educational activity and include name, credentials, educational degree(s), role on the planning committee, and expertise that substantiates their role. Must have 2 RN’s on Planning Committee. There must be one Nurse Planner with a BSN or higher and one other planner to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert). The individuals who fill the roles of Nurse Planner and Content Expert must be identified.
Names and credentials of all individuals in a position to control content (must identify the individuals who fill the roles of Nurse Planner and content expert(s)).
Name of individual and credentials / Individual’s role in activity / Planning committee member? (Yes/No) / Name of commercial interest / Does this person have a degree in Nursing? (Yes/No) / Nature of relationshipExample: Jane Smith, RN-BC / Nurse Planner / Yes / None / Yes / ---
Example: Sue Brown, RNC / Content Expert / Yes / None / Yes / ---
Example: John Doe, PhD / Presenter / No / Pfizer / No / Speakers Bureau
ATTACHMENTS
Please attach the following documentation with cover page before each attachment/section.
If not applicable to your activity, indicate N/A for the cover page for that section
Attachment / Document / What to provide1 / List of planners and presenters/authors and content reviewers / Names and credentials of all individuals in a position to control content (e.g. planners, presenters, faculty, authors, and/or content reviewers) Nurse Planner and content expert must identified.
(See example on previous page.)
2 / BIOI/COI forms
Planning committee members / Qualifications and Conflict of Interest documentation for planning committee members
3 / BIO/COI forms
Presenters/authors / Qualifications and Conflict of Interest documentation for presenters/authors
4 / Agenda/Schedule / An agenda or schedule is needed if an activity is more than 2 hours. Agenda should show time frames for:
1. Welcome
2. Sessions
3. Breaks
5 / Disclosures / Method of Disclosure must show evidence that demonstrates how the required disclosures were provided to learners prior to start of the educational activity. This could be in the form of a PowerPoint slide, Webpage, brochure, page from agenda or disclosure handout that includes:
1. Accreditation approval statement
2. Learner outcomes for the activity
3. Requirements to successfully complete activity and receive contact hours
4. Presence or absence of conflicts of interest and any financial relationships for all individuals in a position to control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers)
5. Commercial support (if applicable)
6. Expiration date (enduring materials only)
7. Joint Providership (if applicable)
Note: Marketing Materials associated with the activity and certificates must clearly indicate the Provider/applicant who is responsible for awarding contact hours and adherence to ANCC criteria
6 / Promotional Material / Advertising material includes any method of announcing an educational activity. This may include a brochure, flyer, announcement, newsletter, memo, e-mail or web site.
Marketing material should include:
1. Activity Title
2. Date and Time (For LIVE activities) or Activity start date, end date and length of time (For ENDURING activities)
3. Target audience
4. Location (For LIVE activities) or Website address (For enduring activities)
5. Presenters/Faculty
6. Activity goal/Learner outcome
7. Educational requirements
8. Joint Provider information
9. Accreditation statement
“ This continuing nursing education activity was approved by the Maryland Nurses Association an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.”
7 / Contact hours calculation sheet
Show time calculation of each session
NOTE: The term “CEU” is not used for Continuing Nursing Education. The correct term is “Contact Hours” / Indicate the following:
1. Number of contact hours requesting approval for.
(One contact hour =60 minutes)
2. Show method of calculation (Provider must keep a record of the number of contact hours earned by each participant) Please indicate if there are any sessions not included in contact hour total
Sample Format:
Date / Activity / Time / Minutes/Contact Hours
1/2/2020 / Dementia / 8:00-9:00 am / 60min/1contact hour
8 / Educational Planning Table / Time for session topics to be discussed, to administer Pre/post tests, Q&A and take evaluations can be included in contact hours, should be clearly shown and separately timed on planning table.
9 / Pre-Tests and Post Tests / If applicable
10 / Certificate of Successful Completion / Documentation of completion and/or certificate must include:
1. Name and address of provider of the educational activity (Web address acceptable)
2. Title and date of completion of educational activity
3. Number of contact hours awarded
4. Official accreditation approval statement
5. Participant Name
11 / Evaluation form / Evaluation required to evaluate:
· Expertise of Presenter
· Effectiveness of presenter teaching strategies
· Participants comprehension of learner outcomes
· Perceived bias during presentations
· Usefulness of content to practice of nursing
· How will participants improve their practice in nursing based on information learned in activity
· Confirmation disclosures were given
12 / Method used to verify participation / Method of collecting participant names should include a unique identifier for each participant, preferable email or mailing address.
For Live activities: Sign in sheet is acceptable
For enduring activities: Participants would not sign a sign in sheet for an enduring activity, therefore a screen shot of webpage participants sign in to participate and a print out of computer log/spreadsheet/ data generated once attendees participate in an activity is acceptable.
13 / Provider Responsibility Agreement / Required
14 / Commercial Support Agreement / If applicable. Provide commercial support agreements for all commercial interests that have provided financial or in-kind support for the educational activity
Determining Conflict of Interest:
Conflict of Interest occurs when:
Individual has ability to control content of activity and has a financial relationship with a commercial interest and/or the products or services of the commercial interest are relevant to the topic of the educational activity
Commercial Interest is any entity producing marketing, reselling or distributing healthcare goods or services consumed by or used on patients. Could also be any entity owned or controlled by such an entity.
Note: Person or organization that is “making or selling” things that are consumed by or used on patients is considered a commercial interest. If you are “providing” patient care or services done in the course of taking care of patients is not a commercial interest
Examples of non-commercial entities:
Hospitals, providers of clinical services, government entities, liability insurance providers, health insurance providers and diagnostic laboratories.
Individual Activity Application Form Template 10.01.15