University of ColoradoDenver, College of Nursing

Office of Lifelong Learning (OLL)

Educational Activity Application

DIRECTIONS:

Please complete this application form and all additional required documentation. All forms must be completed in their entirety. ALL INFORMATION MUST BE COMPLETED IN THIS FORMAT TO BE CONSIDERED FOR REVIEW. Do not change the format of this application or any of the attachments. Pages 7 through 12 are additional forms supplied for your convenience to complete this application. You may need one, two, or all of these additional forms depending on your application responses. Please send one copy of complete, typed, and collated, application with all required attachments and fee to:

Make checks payable to: UCD

UCDenver College of Nursing, Office of Lifelong Learning

Box C288-8, Education 2 North, Room 3220

13120 E. 19th Avenue, Aurora, CO80045

SUBMISSION DATE:

APPLICATION DEADLINE* IS AT LEAST ONE MONTH PRIOR TO THE EVENT DATE. Applications will be reviewed on the second and fourth Wednesday of each month. Be sure to return all required forms with your application.Forms need to be complete and in their original format, please do not alter any forms. In the event the Activity is a Lecture Series, the first threehours of lectures must be defined and completed within the initial application. Lecture information (presenter forms, objectives, evaluations) beyond the first 3 hours must be submitted one month prior to that particular lecture section.

* NOTE: for Activities where the anticipated number of participants is over 100, contact OLL for submission deadline date.

APPLICATION FEE:

All Applicants are charged a fee of$350 for contact hours totaling 1 through 10. For each contact hour over ten, please add $25– this determines the maximum number of contact hours a single person may receive for the event (e.g. For 15 hours, the fee would be $475). Applicants who are not charging participants for their educational activity may inquire about a reduced application fee.

ADMINISTRATIVE FEE:

Applicants are chargeda fee of$10 for each attendeerequesting CNE contact hours(via invoice after the event). This fee covers storage of application, attendance rosters, and any certificate needs for up to six years. Applicants who are not charging participants for their educational activity may inquire about a reduced administrative fee.

Demographic Data

Event title:

Date(s) of event:

Applicant/Organization:

Contact hours requested: (60minutes of content = 1 contact hour)

NOTE: Valid contact hour time includes: any evaluation time, question and answer periods, and discussions.

Introductions, breaks, and lunch are not considered valid contact hour time.

Number of anticipated attendees: Fee charged for participation: $

Has this activity been denied by another continuing education provider? Yes No

If yes, please describe:

Type of activity: Live presentation (i.e. conference, teleconference, etc.)

Packaged-Program (i.e. online modules, articles, etc.)

Learner Directed Independent Study (arranged with nurse planner for one learner)

A.Contact Information:

  1. Contact person: Provide the following information for the contact person for this activity. This is the person that OLL will communicate with regardingreview ofthe application. Note: If this person is also on the planning committee, be sure to include his/her name on the Planning Committee list.

Name and Credentials:

Organization:

Address:

Daytime Phone Number including extension:Fax Number:

Email address:

  1. Planning Committee must include:

a) One RN with a minimum of a baccalaureate degree in nursing and knowledge of the continuing education (CE) process and

b) at least one other individual. They must have relevant content expertise; represent the target audience; and have knowledge

of the CE process. For each person listed on the Planning Committee, please indicate name, degrees, and credentials

below and attach a Data (bio, vested interest, disclosure) Form. A copy of this form is included as the last page of this

application.

RN with minimum of BSN: Jennifer Disabato, MS, RN, CPNP – AC, PC(job description provided by the OLL)

Other Planning Committee Members:

Which person listed above has the relevant content expertise?

Which person represents the target audience?

Data form (bio, disclosure, and vested interest form in one) for each planning committee member is attached.

B.Target Audience and Needs Assessment:

  1. Identify the target audience expected to attend: (Check all that apply) RN Other -Describe:
  1. Check best description of type(s) of needs assessment used: (Check all that apply)

Written Needs Assessment

Learners/Management Requested Event

Quality Studies/Performance Improvement Activities

Trends in Literature, Law,and Health Care

Other -Describe:

  1. Findings from needs assessment:

C.Purpose of the Program/Event:

D.Presenters/authors:In addition to completing the information below, please attach a completed Data Form (biographical/vested interest/disclosure) for each presenter/author. The Data Form is enclosed as the last page within this application. If you have more than three presenters, please attach a separate sheet of paper to complete this list.

1.Presenter/author Name(s), degrees and credentials:

a.

b.

c.

2.Data form (bio, disclosure, and vested interest form in one), declaration for each presenter/authorhas been attached.

For Items E-H, use the Excel 5-column Educational Activity Design Form provided to you. YOU MUST ENABLE ALL MACROS IN EXCEL, WHILE WORKING ON THE DESIGN FORM,IN ORDER FOR THE EVALUATION FORM TO PROPERLY OPERATE. To enable macros in excel for Microsoft Office 2007: Open design form. Go to: File. Excel Options. Trust Center. Trust Center Settings. Macro Settings. Check Enable All Macros. Ok. Ok. CLOSE DOCUMENT. Then REOPEN the document and begin to fill the design form in….when finished click on second tab of excel document. To enable in excel for Microsoft Office 2003: Open design form. Go to: Tools – Macro – Security. This will pop upa new window. In this window they will want to select the low security setting. Click OK.CLOSE DOCUMENT. Then REOPEN the document and begin to fill the design form in….when finished click on second tab of excel document.

The second tab on this excel document is an auto-populating evaluation form supplied for your convenience. Make additional copies of this form as necessary and number and collate the pages appropriately. If the activity is more than three hours, documentation for only three hours is required to be submitted. An agenda or outline with the entire timeframe must be submitted so that contact hours can be correctly calculated. However, the applicant must maintain documentation for the full activity. WHEN FINISHED WITH THE DESIGN FORM, PLACE THE ORIGINAL SECURITY SETTING FOR MACROS BACK ON YOUR COMPUTER. If you do not fix your macro security when finished with the design form, you are placing your computer at risk if you should open another document with macros from an unknown source.

E.Objectives: Indicate what the learner will be able to do at the conclusion of the activity. An average of 1-2 objectives per hour is realistic. Please number each objective consecutively. Indicate applicability to each member of the target audience if the objective deals with hands-on clinical practice. Please see the third tab [“helpful hints”] of the Educational Activity Design Form for suggested verbs(i.e. demonstrate, compare, differentiate, etc.) to use when developing your objectives.

F.Content: List the content for each objective. Content must flow from, and be more than a restatement of, the objective.

Numbering must be consistent with the related objective.

G.Time frame: List number of minutes for each objective.

H.Teaching-Learning Strategies: List the methods, strategies, materials and resources to be used by faculty to cover each objective.

I.Co-providership: A Co-provider is defined as an entity who is an approved provider of Continuing Nursing Education contact hours, who is actively involved in planning, developing, and implementing the educational activity. If this activity involves a co-provider, a written agreement defining roles must exist between our organization and theirs. See page 8 of this application for the co-provider written agreement form. (If there is NO co-provider: check #1; if there is a co-provider(s): answer #2, #3 and #4 and submit a co-provider written agreement form[page8] for each co-provider involved.)

1.This activity will not be co-provided.

2.Co-providership of this activity has been arranged with the following organization(s):

  1. As the Colorado Nurses Association approved applicant, OLL will maintain responsibility for determination of objectives and content, selection of content specialists and faculty, awarding of contact hours, record keeping and evaluation for six years.
  2. I have included a written agreement with the co-providers which outlines the above.
  1. Commercial Support: Commercial Support is defined as financial or in-kind contributions given by a commercialinterest,which is used to pay all or part of the costs of a CNE Activity.If this activity involves commercial support, awritten agreement regarding the support to be provided/accepted must exist between our organization and theirs. See page9 and 10of this application for the commercial support agreement form. (If there is NOcommercial support: check #1; ifthereiscommercial support: answer #2, #3, #4 and #5 and submit a commercial support agreement form[page9 and10]for eachentityinvolved.)
  1. This activity has no commercial support.
  1. Commercial support has been provided by the following organization(s):
  1. Content integrity has been/will be maintained by: (Check all that apply)

a.Our commercial support policy/procedure has been discussed with those providing commercial support.

b. Our commercial support policy/procedure has been shared in writing with those providing commercial support.

c. Faculty has been informed of our policy/procedure regarding commercial support.

d. The session will be monitored and violators of policy will not be asked to present again.

e. Other -Describe:

  1. The following precautions have been taken to prevent bias in the educational content.

a. Our position on commercial support and bias has been discussed with each presenter.

b. Each presenter has signed a statement that says s/he will present information fairly and without bias.

c. The session will be monitored and violators of policy will not be asked to present again.

d. Other - Describe:

  1. Signed commercial support agreement attached.

K.Evaluation:Please keep in mind, the second tab on the Excel 5-column Educational Activity Design Form provided to

you, is an auto-populating evaluation form, supplied for your convenience.

  1. Check or describe the methods of evaluation to be used: (Check all that apply)

Evaluation Form or Attitude Scale

Pre and/or Post-test

Return Demonstration

Structured Interview

Other -Describe:

  1. Attach a copy of the evaluation(s) tool to be used for this event. The evaluation tool should include, at a minimum, all of the objectives on the Educational Activity Design Form, and evaluation of each faculty member.
  1. The category of evaluation to be used for this activity: (Check all that apply)

Learner satisfaction

Knowledge enhancement

Skill and attitude change

Change in practice/performance

Relationship of the practice change to quality of service

  1. Check the best description or describe how 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:

  1. Learner Feedback: Check the best description or describe how learners will be provided feedback.

Question and answers during activity

Return results of testing

Provide certificate

Follow up communication

Other -Describe:

L.Verifying Participation and Successful Completion:

Attendance/participation will be verified at the event through sign-in sheets/attendancesheets.Attendees must

sign in at each session or each day of an event in order to get credit for participation and earn available

contact hours.

Other -Describe:

  1. Criteria for successful completion include: (Check all that apply)

Attendance of entire event

Attendance of at least 80% of event

Completion/submission of evaluation form

Achieving passing score on post-test

Other -Describe:

  1. Documentation of completion: Acompleted certificate will be awarded to learners. See sample on page 6. This certificate will include the name of the learner, number of contact hours awarded, name and address of the provider of the educational activity, title and date of the activity, and will include the official approval statement:“University of Colorado Denver, College of Nursing, is an approved provider of continuing nursing education by the Colorado Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.”
  1. How would you like the certificates to be awarded after this Educational Activity?

a. Email

b.Distribute at end of activity (only available for one day events with prior acceptance)

c.U.S. Mail – all requested certificates are sent to the Applicant for distribution to participants.

  1. Disclosures:
  1. Learners will be informed of criteria for successful completion by:

Information on advertising material

Verbal statement at beginning of activity

Written information on handouts

Other -Describe:

  1. Learners will be informed of conflicts of interest or lack thereof for planners and presenters by:

(NOTE: Not applicable is not an acceptable response)

Announcement at beginning of session:

This option must be documented in writing that it occurred by a representative of the provider who attended the event. Use Verbal Disclosure Form on page 11 of this application.

Name of documenter:

Information provided on advertising.

Information provided on handouts.

Signs placed inside or outside of presentation room.

Other -Describe:

  1. Learners are informed of commercial support or lack there of by:

(NOTE: Not applicable is not an acceptable response)

Announcement at beginning of session:

This option must be documented in writing that it occurred by a representative of the provider who attended the event.Use Verbal Disclosure Form on page 11 of this application.

Name of documenter:

Information provided on advertising.

Information provided on handouts.

Signs placed inside or outside of presentation room.

Other -Describe:

  1. Learners are informed of non-endorsement of products ifcommercial support received.

No commercial support being received for this event.

Information provided on advertising.

Information provided in handouts.

Verbal statement made at the beginning of the session.

Other -Describe:

  1. Learners are informed of discussion of off-label use by faculty by:

Faculty has attested they will not discuss off-label usage of products. (No statement needs to be made.)

Faculty will state at the beginning of their session that there will be discussion of off-label use ofproducts.

This option must be documented in writing that it occurred by a representative of the provider who

attended the event.Use Verbal Disclosure Form on page 11 of this application.

Information will be provided in the handouts.

Other -Describe:

  1. Contact Hour Calculation:

If live presentation, attach an agenda or schedule for the entire event. Clearly state time spent on welcome, introductions, pre/post tests, breaks and evaluation. The time frames on the schedule and the objective/content outline pages must match and must support the number of contact hours requested. 60 minutes equals 1 (one) contact hour.

If packaged program,describe how contact hours were calculated.

If independent study type activity, describe how contact hours were calculated.

  1. Advertising Material:All Advertising must include the CNA approval statement as follows:“University of Colorado Denver, College of Nursing, is an approved provider of continuing nursing education by the Colorado Nurses Association, an accredited approver by the AmericanNursesCredentialingCenter’s Commission on Accreditation.”

Statement incorporated in advertising material. (initial on line)

Attach a copy of the advertising material* including relevant pages of the web site (if applicable). Type of advertising:

Flyer/brochure

Memo/Letter

Meeting Notice

E-mail

Web site**

Other -Describe:

* If a mock-up is included with the application, the final copy must be submitted as soon as it is completed.

** If advertising is via the web site, include the address so that reviewers can find this information. Include the URL (web site address) for the approval statement and advertising material.

The URL is:

  1. Record keeping:

All correspondence, complete copy of application, all attachments and corrections, records of attendance, summative evaluation(s) and contact hours will be maintained in a retrievable file which is accessible to authorized personnel only for six years. Records will be filed and stored at the University of Colorado Denver,College of Nursing’sOffice of Lifelong Learning.

  1. Upon completion of educational activity, you are required to return the following items to OLL:
  1. The original Sign-In Sheets with a summary of total participants and number of participants that are RN’s
  2. An Evaluation Summary
  3. An electronic list emailed to: ) ofparticipantsto be awarded (or awarded) certificates and the number of contact hours each should receive (received)
  4. The Verbal Disclosure Documentation form
  5. Once invoiced by OLL, Applicant (or designee) must submit a $10Administrative Fee perparticipant receiving a contact hour certificate.

END OF APPLICATION

CHECKLIST

BEFORE SUBMITTING THIS APPLICATION,

HAVE YOU REMEMBERED TO INCLUDE THE FOLLOWING?

One copy of the application – typed and collated. Include one copy of allrequired documents with the application.

Application review/acceptance fee

Data (Biographical/Vested Interest/Disclosure) Form for eachPlanner and Presenter.

Educational Activity Design Form (either live presentation, or self-study as applies)

Evaluation form(s)

Sign-in sheet with top portion completed.

Program Schedule/Agenda if event is over two hours

Advertising material, with mandatory official CNA approval statement, even if in draft form

NOTE: If there are any advertising issues, please direct them to Jennifer Disabato(r 303-724-0604). As part of her roles in the Planning Committee, she oversees any and all advertising.