INDIVIDUAL EDUCATIONAL ACTIVITY APPLICATION
Directions: Please carefully review the WNA CEAP Individual Educational Activity (IEA) Application Instructions (found on the WNA CEAP website) as you begin planning your educational activity. The Instructions are a guide that will help you complete the Application correctly. Applications will be evaluated for completeness, and the presence of all required attachments at the time of submission is expected. Incomplete applications will not be reviewed.
NOTE: It is imperative that revisions and/or clarification requested by the reviewers be provided by the deadline given. Failure to provide requested information by the deadline may result in denial of the application.
Questions: Please contact the WNA office at (800) 362-3959; (608) 221-0383; or .
Applicant Organization:Mailing Address:
Nurse Planner Name and Credentials
Nurse Planner Preferred Email:
Nurse Planner Preferred Phone:
Note: The CNE Nurse Planner must be available to WNA CEAP Nurse Peer Reviewers to answer questions regarding the applicant organization and the information provided in this application.
Contact Name and Credentials:
(if different from above):
Contact Preferred Email:
Contact Preferred Phone:
A. Title of Educational Activity:
B. Activity Format and Dates Available:
NOTE: Provide the anticipated date of the first scheduled presentation or publication. If you are unsure of the specific date, then provide a projected date. “TBD” or similar phrases are not acceptable.
Live Event – indicate type:On-site class / Series of classes / Conference / Teleconference / Live Webinar
Other (Describe):
Initial activity date(s): / Will the activity be repeated? / YES / NO
Location of activity (if on-site):
Enduring Material – indicate type:
Article in publication / Printed self-study program / Online self-study program / CD/DVD
Other (Describe):
Start date: / Expiration date*:
If web-based activity, provide URL (website address):
C. Anticipated number of total attendees:
D. Anticipated total contact hours:
Anticipated number of contact hours per participant:
Step 1: Is your organization a ‘commercial interest’?
Does your organization produce, market, re-sell, or distribute health care goods or services consumed by, or used on, patients?
NO – Your organization is eligible to apply for IEA approval; continue to Step 2YES – You are still eligible to apply if you identify your organization as one of the following: *
Non-profit organization
For-profit and nonprofit hospital, nursing home, or rehabilitation center
Government organization
Non-health care related company
A single-focused organization devoted only to providing continuing nursing education
* If you checked ‘YES’ and have not identified your organization as one of the types above, you may not be eligible to apply.
Please contact Megan at the WNA office before proceeding with this application.
Step 2: Does the planned activity meet the definition of continuing nursing education?
Does the planned educational activity meet all of the following requirements?
· Content must enable the learner to acquire or improve knowledge or skills beyond basic knowledge
· Content must enhance professional development or performance of the nurse
· The activity must be at least 30 minutes in length
· The activity must be based on current and best-available evidence
YES – continue to Step 3NO – This activity is not eligible for review.
Step 3: Is there a qualified individual serving as the CNE Nurse Planner for this continuing education activity?
Does the Nurse Planner meet all of the following requirements?
· Is currently licensed as a registered nurse
· Holds a baccalaureate degree or higher in nursing
· Is not an employee or representative of any commercial interest entity
· Has no relevant relationship with a commercial interest (conflict of interest)
· Is actively involved with the planning, and will continue to be actively involved in the implementation and evaluation of this educational activity
YES – See contact information on page 1 of this application.NO – This activity is not eligible for review.
Step 4: Are ‘Joint-Provider’ organizations eligible to participate in planning this activity?
Are other organizations involved as Joint-Providers in planning, developing, and implementing this activity?
NO – continue to Step 5YES – Is any Joint-Provider organization a ‘commercial interest’?
NO – continue to Step 5
YES – This activity is not eligible for review.
Step 5: What is your organization’s history with continuing education approving/accrediting bodies?
A. Has your organization ever been denied accreditation by ANCC or had its Accredited Provider status suspended or revoked?
NOYES - Provide the following information:
Date of Action: / Action taken: / Denial / Suspension / Revocation
Brief description:
B. Has your organization ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by Wisconsin Nurses Association or another ANCC Accredited Approver?
NOYES Provide the following information:
Date of Action: / Action taken: / Denial / Suspension / Revocation
Brief description:
NOTE: An affirmative answer in Step 5 does not affect eligibility to apply, but you will be contacted by WNA CEAP to discuss the circumstances disclosed.
As the CNE Nurse Planner for this educational activity, I hereby certify and attest that:
· the information provided in this application is true, complete, and correct;· I have been actively involved in the planning, implementation, and evaluation of this continuing nursing education activity and assure adherence to ANCC /WNA CEAP criteria;
· the applicant organization will comply with all eligibility requirements and approval criteria throughout the approval period;
· I will notify WNA CEAP promptly if, for any reason, the applicant does not maintain compliance with eligibility requirements and approval criteria; and
· I agree to notify WNA CEAP before any changes are made to this educational activity as put forth in this application.
I understand that any misstatement or falsification in this application will be sufficient cause for denial, suspension, or termination of approval of this activity and failure to abide by standards and criteria of the ANCC and WNA CEAP may result in revocation of activity approval.
Electronic Signature: An ‘X’ in the box below serves as the electronic signature of the CNE Nurse Planner.
Name and Credentials: / Date:Total payment:
Check enclosed payable to the Wisconsin Nurses Association.To pay by credit card, please contact Megan at the WNA office at (800) 362-3959 or (608) 221-0383.
A. Will this activity be jointly-provided?
NOYES – answer questions below:
1. List the organization(s):
/ Attach a copy of the signed WNA CEAP Joint-Provider Agreement for each organization listed above.2. Indicate the aspects of the educational activity development that the CNE Nurse Planner will maintain responsibility for/control over in the presence of joint-providership:
Determination of educational objectives and contentFinal selection of planners, presenters, faculty, authors and/or content reviewers
Awarding of contact hours
Developing evaluation methods
Management of commercial support
Recordkeeping procedures
Name of your organization will be prominently displayed on all marketing material and certificates
A. Identify the target audience for this activity: (check all that apply)
Note: At a minimum, the target audience must include Registered Nurses.
RNsAdvanced Practice RNs
RNs in Specialty Areas (Identify Specialty):
Interprofessional (Describe):
Other (Describe):
B. Identify the method(s) used to identify the need for this activity? (check all that apply)
Survey of stakeholders, target audience members, subject matter expertsRequesting individual input from stakeholders such as learners, managers, or subject matter experts
Reviewing outcomes of quality studies and/or performance improvement activities
Reviewing evaluations of previous educational activities
Reviewing trends in literature, law and/or health care
Other (Describe):
C. Indicate the source(s) of supporting evidence for the needs assessment data:
Note: These should be consistent with the needs assessment methods listed above in B.
Literature review
Outcome data
Survey results of stakeholders or learners
Quality assurance/improvement data
Requests (documented – e.g., via phone, in person or by email)
Written evaluation summary requests
Other (Describe):
/ For each ‘source of supporting evidence’ identified above, attach a brief summary of the needs assessment findings.
D. Briefly describe the problem or need for improvement you want to address with this educational activity:
E. Complete the table below to show the gap(s) the educational activity is designed to address.
Related to the problem you are trying to solve or the improvement you are trying to make:
What is the current practice of the target audience now? / Desired State: What should nurses be doing in practice? / How do we know this is a problem (what data or information do we have?) / Is the Gap in Knowledge, Skill or Practice? ** / How will we know if the education was successful? / Is there data we can collect to show that our education was successful?If yes:
** Gap in knowledge = nurses don’t know or don’t have information about something
Gap in skills = nurses don’t know how to do something
Gap in practice = nurses are not doing something they need to be doing in their practice
F. Identify the purpose for the activity.
“The purpose of the activity is to enable to learner to: [DO WHAT IN PRACTICE].”
· A CNE Nurse Planner Biographical Data/COI Form or Planner/Faculty Biographical Data/COI Form must be completed and submitted for each planner, presenter/author, and content reviewer (if applicable).· A member of the planning committee reviews and signs the CNE Nurse Planner COI Form. The CNE Nurse Planner must review and sign the COI form for all other planners, all presenter/authors, and all content reviewers (if applicable).
· Regardless of the length of the program (i.e. even if the program is longer than 3.0 contact hours), Biographical Data/COI Forms must be submitted for all presenters/authors.
· If a COI is disclosed on the COI form by anyone involved in the activity, the CNE Nurse Planner first determines if the disclosure is relevant, and if yes, what was done to resolve the conflict of interest.
Please see the WNA CEAP Individual Educational Activity (IEA) Application Instructions and Glossary for additional information on ‘COI’ and the CNE Nurse Planner’s role in identifying, resolving, and disclosing a COI.
A. Planning Committee: Must include at a minimum the CNE Nurse Planner and one other planner, and at least one member must have appropriate subject matter expertise for this educational activity. List all planners and indicate with an ‘X’ the ‘Content Expert(s)’.
Name and credentials of CNE Nurse Planner / Content Expert*Name and credentials of all other planners / Content Expert*
(Add more rows as needed by placing cursor outside of last row and clicking ‘Enter’ key.)
*if Content Expert is checked, this should be reflected on the individual’s Biographical Data/COI Form.
/ Attach the CNE Nurse Planner Biographical Data/COI Form./ Attach the Planner/Faculty Biographical Data/COI Form for each additional planner in the same order as listed above.
B. Presenters/Authors
1. Identify the necessary qualifications of presenters/authors for this educational activity: (check all that apply)
Content expertise/recognized expert in the fieldDemonstrated comfort with teaching methodology (e.g., web-based, audience response system, etc.)
Presentation skills
Familiarity with target audience
Other (Describe):
2. Identify way(s) the planning committee assured the qualifications of the selected presenters/authors were appropriate and adequate: (check all that apply)
Review of resume/CVRecommendation by colleagues
Review of literature written by presenter/author
Observation of previous presentation by presenter/author
This new presenter/author will be mentored by:
Other (Describe):
3. List the names and credentials of all presenters/authors below.
(For more than 10 presenters, submit an agenda or list with the names and credentials of all presenters/authors clearly identified).
C. Content Reviewers: Were content reviewers utilized in reviewing materials for this activity?
NOYES – Name(s) and credentials:
/ Attach Planner/Faculty Biographical Data/COI Form for each Content Reviewer.
D. Was a conflict of interest (COI) identified and resolved for any planner, presenter/author, or content reviewer of this activity?
NOYES* – Record strategies utilized to resolve the COI on the individual’s Biographical Data/COI Form.
* Information about the specific COIs identified and resolved will be part of the required disclosures provided to participants for this activity.
A. Educational Objectives, Quality of Content, Time Frame, Presenter, Teaching-Learning Strategies, and Evidence-Based References: Use the Education Planning Table specific to ‘live event’ or ‘enduring material’ to document each of these for the educational activity. Refer to the IEA Application Instructions for a description of each criterion.
/ If this educational activity is 3 contact hours or less: Attach Education Planning Table(s) for the entire activity./ If this educational activity is more than 3 contact hours:
· Attach Education Planning Table(s) for at least 3 contact hours of the activity.
· Submit the schedule/agenda and evaluation for the entire activity.
NOTE: WNA CEAP reserves the right to request the Education Planning Table(s) for the remainder of the activity as needed for review.
B. Learner Feedback
Identify way(s) learners will be provided feedback on learning/performance:
Self-check or self-assessment questionnaires
Audience response system
Engaging learners in dialogue
Return results of testing
Feedback on assignments
Return demonstration
Role play
Other (Describe):
C. Verify Participation
Identify method(s) for verifying learner participation in the activity.
Sign-in sheet / scanning system at event
Signed attestation statement by participant verifying completion of part or all of activity
Collection of participation verification via computer log
Other (Describe):
D. Determination of Successful Completion
1. Identify all criteria for successful completion of this educational activity:
Attendance at entire activityAttendance at one or more individual sessions within the activity
Submission of completed evaluation form
Achieving passing score on post-test – passing score is:
Submission of required assignment(s)
Return demonstration of skill
Other (Describe):
/ Attach a copy of the post-test utilized (if applicable).
2. Identify rationale for choosing successful completion requirements: