TNA Application April 2010

8/4/2019 TNA Application April 2010

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April 2010

A. Assessment of Learner NeedsInstructions: Place a check mark or “x” next to applicable statements or identifying characteristics.(check as many as apply)

The need for this activity was identified by:

___Previous course evaluations ___ Reports on trends in health care system

___ Quality improvement data ___Consumers ___ Nursing experts ___ Professional organizations

___ Research findings ___ Needs assessment or survey

___ Specifically requested ___ Societal and organizational trends

___The Registered Nurse ___ Legislation

___ Reports of advances in treatments and technology

___Other _______________________________________

Supporting evidence/documentation for the above selection(s) is on file and available upon request.

______ Nurse Planner Initials

B. Determination of Target Audience

1. Registered Nurses

___Staff Nurses ___Advanced Practice Nurses ___Other (Specify):___________

2. Level of RN Learner for this Activity

___Novice ___Intermediate ____Advanced

3. Location of Participant Clinical Area of Practice

___ Rural facility ___ Medical-Surgical

___Suburban facility ___ Maternal Child Health

___ Urban facility ___ Community/Public Health

___Military facility ___ Psych/Mental Health

___Skilled Nursing facility/LTC ___Critical Care/Emergency/Operating Room

___Home Health facility ___Pediatrics

___Education ___Other: ____________________________

___Other: ______________________

C. Learning Goal/Purpose Statement

The purpose is a statement of intent that reflects the rationale for the activity and describes how thisactivity will enrich the Registered Nurse’s contributions to quality health care and his or her pursuit of

professional career goals by addressing identified gaps in knowledge, skills, attitude or practice basedon the needs assessment. NOTE: Consider HOW you expect the nurse to utilize the informationpresented once he/she is back in their workplace.

Form11042010



April 2010

D. Planning Committee

Submit a Biographical Data form and a Conflict of Interest Disclosure form for each member serving onthe Planning Committee. This includes faculty, content specialists and authors. Minimum planningcommittee membership is two. Resumes and curriculum vitas are NOT accepted.

Nurse Planner : Must have a baccalaureate or higher degree in nursing, and must have education or

experience in the field of education or adult learning. The Nurse Planner guarantees that TNA andANCC COA criteria guide the development, implementation and evaluation of this activity. (Alsoresponsible for assessing needs, planning, implementation and evaluation of activity.)

Name and Credentials: _____Bonnie Schranner, MSN, RN, BC ________________________________________________________________ *********************************************************************************************************************

Target Audience Representative: (Must be a RN. Gives insight into the needs of the target

audience.)

Name and Credentials: _____________________________________________________________________

*********************************************************************************************************************

Faculty or Content Specialist: (Must have documented qualifications that demonstrate education,

knowledge, and expertise in the subject matter.)


*********************************************************************************************************************

Others Participating on the Planning Committee


Role:_______________________________________________

*********************************************************************************************************************


Role:_______________________________________________

*********************************************************************************************************************


Role:_______________________________________________

*********************************************************************************************************************

Duplicate page for additional planning committee members.

Form11042010



EDUCATION DOCUMENTATION FORM

This format is required. Instructions for provider- directed activities : Use this five-column format to provide documentation of Educational Criteria:

E. Objectives, F. Content, G. Time Frames, H. Faculty/Content Specialists, and I. Teaching Learning Strategies to show that the activity supports the purpose/goal(s).

F or learner-paced activities: Utilize a three-column format that includes objectives, content and teaching method & strategies.

Title of Activity: _________________________________________________________________________________________________________________

E. OBJECTIVES F. CONTENT G. TIME FRAME H.FACULTY/CONTENT SPECIALIST

I. TEACHING LEARNINGSTRATEGIES

List the learner objectives in behavioral/measurable outcomesfor evaluation. One verb per objective.

Provide an outline/description of thecontent presented and indicate to whichobjective the content is related. It must be more than a restatement of theobjective.

Provide a time framein minutes for eachobjective for provider-directedactivities.

List the faculty for eachobjective in provider-directed activities.

List the teaching strategies,resources, &/or referencesutilized by each faculty for each objective – such asresources, materials, deliverymethods.

This format is required



J. Faculty or Content Specialist Qualifications

Submit a Biographical Data form and a signed Conflict of Interest Disclosure form for eachfaculty/content specialist member. Resumes and curriculum vitas are NOT accepted.

Name: __________________________

Indicate the faculty/content specialist’s participation in the planning process.

Planning ___ Attended planning meeting

___Individual contact to discuss content and objectives

___Developed objectives

___Developed content

___Other, please describe____________________________________________________

The faculty/content specialist’s biographical data form was reviewed and approved by the planning

committee to ensure qualifications were met. ___________( Nurse Planner initials required)

Name: __________________________

Indicate the faculty/content specialist’s participation in the planning process.Planning ___ Attended planning meeting







**************************************************************************************************************

Name: __________________________

Indicate the faculty/content specialist’s participation in the planning process.Planning ___ Attended planning meeting







**************************************************************************************************************

Duplicate form for additional faculty.



K. Verifying Participation and Successful Completion by the Participant.

Instructions: Place a check mark or “x” next to applicable statements or phrases and/or describe your method for verifying participation and successful completion.

1. The CNE provider maintains verification of a nurse’s participation through use of aunique identifier. Note: The BON discourages the use of the RN license number or SSN

as a discriminator for those with similar names. A common alternative is the use of birthmonth and day.

___ Sign In Sheets ___ Self-reported attendance

___ Roll Call ___ Registration Forms

If NOT one of the above, describe method of verifying participation below.

2. Describe the criteria/method/process for verifying how you determined that the nursesuccessfully completed your educational activity.

___ Achieving a passing score on post-test ___ Attendance of entire activity(attach a copy of the post-test)

___ Interview ___ Clinical observation

___ Return skill demonstration/competency assessment__X Completion/submission of evaluation form

___ Completion of self-study packet ___ Other, please describe:

Rationale for above selection(s):

__________________________________________________________________________________

__________________________________________________________________________________

L. Awarding Contact Hours

Number of contact hours to be awarded:_ ______ (Up to the 1/100th as appropriate)

1. Provider-Directed:

Presentation time plus evaluation time divided by 60 minutes equals total number of contact

hours.

________________ divided by 60 minutes = _____. __ __ contact hours

Total number of minutes Do not roundfrom column G of theEducation Documentation form

2. Learner-Paced:

____ Pilot Study ____ Historical Data ____ Peer Reviewed ____ Other: (Explain) ___________________________________________

Describe the method and rational used in determining the number of contact hours to be awardedfor successful completion of this activity. Contact hours must be calculated in a logical, defensiblemanner.



M. Activity Evaluation

Instructions: Place a check mark or “x” next to applicable statements or phrases. (Check as many asapply.)1. Identify which evaluation category(ies) is most appropriate for this activity and provide the

rationale and outcome measurement in the space below. _X__ Learner satisfaction (Required of all activities)

HIGHER LEVELS OF EVALUATION

____ Knowledge enhancement

____ Skill and attitude change

____ Change in practice/performance

____ Relationship of the practice change to quality of service

Based on the evaluation category(ies) selected above, describe how this/these evaluationcategories could be assessed long-term as related to improving patient/ client outcomes.(Complete only the category(ies) chosen above.)

Learner satisfaction: ____Activity Evaluation Tool______________________________

Knowledge enhancement:_____________________________________________

Skill and attitude change:_______________________________________________

Change in practice/performance:_________________________________________

Relationship of the practice change to quality of service:______________________________________________________________________

____________________________________________________________________________

2. Describe the method(s) used by the learner to evaluate this activity:

____ Post-test (passing score: ____)

__X_ Rating scale

____ Structured interview

____ Attitude scale ____ Direct observation of skill performance

__X_ Self-reported achievement of each measurable objective

____ _ Other: (Describe) _____________________________________________________

3. Describe how evaluation data will be used:

____ Make revisions to this or future programs

____ In the development of the nurse’s portfolio

_X_ Shared with the planning committee members and faculty

____ Future planning of educational activities

____ _ Other: (Describe) _______________________________________________________ 4. Describe how the learners will be provided feedback:

____ Questions and answers during activity

____ R eturn results of testing

__X_ Certificate of successful completion

____ _ Follow-up communication

____ _ Other: (Describe) _________________________________________________________



5. Describe how faculty will be given feedback (for provider-directed activities only):

____ Informal feedback ____ Post activity feedback

____ Written evaluation ____ Other: (Describe) __________________

Provider-Directed evaluations must include the following eight criteria:1. Learner’s achievement of EACH objective.2. Expertise of EACH individual faculty.

3. Relationship of objectives to overall purpose of the activity.4. Effectiveness of teaching strategies.5. Appropriateness of the physical facilities.6. Perceived bias during a presentation.7. Outcomes measurement assessment based on evaluation category.8. Confirmation of disclosure.

Learner-Paced evaluations must include the following seven criteria:1. Learner’s achievement of EACH objective.2. Effectiveness of teaching/learning resources.3. Relationship of objectives to overall purpose of the activity.4. Time required of the learner to complete the activity.5. Perceived bias during a presentation.6. Outcomes measurement assessment based on evaluation category.

7. Confirmation of disclosure. A COPY OF YOUR EVALUATION TOOL MUST ACCOMPANY THIS ACTIVITY FORM.

N. Promotional Materials

A copy of the promotional materials must accompany this activity form. Don’t forget to use theappropriate statement. This statement must stand alone.

(University Health System) is an approved provider of continuing nursing education by theTexas Nurses Association, an accredited approver by the American Nurses CredentialingCenter’s Commission on Accreditation.

O. Documentation of Completion

The certificate of successful completion given to the participant must include the following information:

a. Name and address of approved provider, including street, city, state, zipb. Provider ID number c. Name of participant d. Title of activity e. Number of contact hours awarded to participant f. Day, month and year of activity presentation (or completion date if learner-paced)g. City & State in which activity held/presented(not required for learner-paced activities)h. Correct TNA approval statement.

COPY OF YOUR CERTIFICATE OF SUCCESSFUL COMPLETION MUST ACCOMPANY THIS ACTIVITY FORM WITH THE CORRECT STATEMENT.

(University Health System) is an approved provider of continuing nursing education by theTexas Nurses Association, an accredited approver by the American Nurses CredentialingCenter’s Commission on Accreditation.



P. Sponsorship and Commercial Support Guidelines

Instructions: Place a check mark or “x” next to applicable statements or phrases.

1. Does this activity receive sponsorship or commercial support? Yes ____ No ____

If no, proceed to Section Q.

If yes, list the name(s) of representatives and company below, and complete #2 and #3

below. (Add lines as necessary.) ____________________________________

2. Describe how content integrity of the educational activity is maintained:

____ Research conducted by commercial companies are designed and presented with scientific objectivity.

____ Learners are informed of any or possible off-label use of a commercial product that is referenced in the ac

____ Sponsor/Commercial supporters did not influence the planning or presentation of the activity.

____ Sponsor/Commercial products are distinguished as separate from the activity.

____ Sponsor/Commercial supporters do not interfere with the planning or presentation of the activity.

3. Describe what/how precautions are taken to prevent bias in the educational content:

a. ____ Content and format was reviewed to assure that it did not specify proprietary business

and/or commercial interest.

b. ____ Generic names were used.

c. ____ Names were made available from several companies.

IF THIS ACTIVITY RECEIVES SPONSORSHIP OR COMMERCIAL SUPPORT, A COPY OF THESIGNED “COMMERCIAL SUPPORTER AGREEMENT” OR A “SPONSOR AGREEMENT” MUSTACCOMPANY THIS APPLICATION. SPONSORS/COMMERCIAL SUPPORTERS MUST BELISTED ON THE PROMOTIONAL MATERIALS.

Q. Conflict of Interest Guidelines:

Were any conflicts of interest identified? Yes ____ No ____

If no, proceed to section R.If yes, describe below how conflicts of interest were resolved.

1. ___ Conflict was discussed with the individual.

2. ___Presentation was restricted to clinical data.

3. ___ Faculty/content specialist’s lecture/topic was reassigned.

4. ___ Session will be monitored to ensure conflict does not arise.

5. ___ Talking points/outline were provided.

6. ___ Data, slides were added or removed.

7. ___ Content was reviewed to assure it was free of sponsorship/commercial bias.

8. ___ Other (Describe):____________________________________________________________



R. Disclosures Provided to Activity Participants

Required disclosures provided to activity participants. Describe the METHOD (such as verbal,handout, flyer, brochure) used to notify participants at the beginning of the education activity of thefollowing: (Multiple methods or a single method are appropriate, check all that apply.) All componentsmust be addressed. Components 2 through 6 must be addressed in the disclosure as to whether there is actual, potential, or no disclosure to be made.Check disclosure methods you will use.

When this information is disclosed verbally at the activity, the approved provider must be able tosupply TNA with written documentation that appropriate verbal disclosure occurred at the activity. The

approved provider unit representative in attendance at the time of the verbal disclosure must attest, inwriting:a. That disclosure did occur.

b. What information was disclosed.

A COPY OF THE DOCUMENTATION OF THE WRITTEN OR VERBAL DISCLOSURES THATADDRESS ALL OF THE ABOVE COMPONENTS MUST ACCOMPANY THIS APPLICATION.

S. Co-Providership (if applicable)

Will the activity be co-provided? Yes _____ No _____

If yes, submit a copy of the written co-provider agreement.Note: As the Approved CNE Provider of this educational activity, the following items are your

responsibility:• Determination of the educational objectives and content •

Selection of content specialists, planners, and activity faculty • Awarding of contact hours• Recordkeeping procedures• Evaluation methods and categories, and • Management of any sponsorship or commercial support

FOR LEARNER-PACED ONLINE ACTIVITIES, INCLUDE THE FOLLOWING WITH YOUR ACTIVITYAPPLICATION:

Print screen of:• Disclosure to Participants• Evaluation Tool• Certificate of Successful Completion

Disclosures PromotionalMaterial Verbal Handout AV Slide Posted atRegistration

1. Requirements for successful completion

2. Conflicts of Interest

3. Disclosure of Relevant FinancialRelationship(s) andMechanism to Identifyand Resolve Conflicts of Interest.

4.CommercialSupport/Sponsorship

5.Non-endorsement of products

6.Off-label use

7. Expiration Date for Awarding ContactHours(EnduringMaterials Only)



BIOGRAPHICAL DATA FORM FOR ACTIVITIES

Instructions: Use this format to provide documentation of an individual’s expertise as a planning committee member or as faculty/content specialist for this activity. Submittedinformation must not be more than 2 pages. Do not attach any additional material. Check which role you are fulfilling:

Nurse Planner Target Audience Representative

Faculty

Content Specialist

Other _______________________________(explain)

Name and Degrees:

Preferred Contact Address:Number and Street:City, State and Zip Code:

Preferred Contact Telephone:FAX:E-mail Address:

Present Position:(Employer, job title)

Education (include basic preparation through highest degree held) Reminder: A degree is awardedfrom an academic setting; a license is issued by a regulatory agency.

Institution (Name, Major Area Year DegreeDegree City, State) of Study Awarded

1.

2.

3.

4.

Biographical Data

Use the space below to briefly describe your professional experience as it relates to your role, asindicated above, in this continuing nursing education activity: (add additional areas as needed that relateto this role.) Based on the role(s) checked above, complete the appropriate following statement:

• As Nurse Planner, I have education or experience in the field of education or adult learning andknowledge related to ANCC/TNA criteria through:

• As Target Audience Representative, I represent the target audience by:

• As Faculty/Content Specialist, I have content expertise in this topic by:

• Other : As _________________, my professional experience as it relates to this continuing

nursing education activity is:



UNIVERSITY HEALTH S YSTEM

CONFLICT OF INTEREST DISCLOSURE

As an approved provider by the Texas Nurses Association, it is the policy of University Health System to ensure balanceindependence, objectivity and scientific rigor in all of its continuing nursing education activities. All planning committeemembers and presenters/content specialists/authors participating in a University Health System activity must disclose tName of Approved Provider any financial relationships that they or an immediate family member may have with anycommercial interest in any amount occurring within the past 12 months that create a conflict of interest. A conflict ointerest would also occur if you have any potential to benefit personally or professionally from the presentation (work for a

proprietary company presenting the learning activity, have written a book about the topic, provided consulting services related tothe topic, etc.). An “immediate family member” is defined as someone with whom you have a relationship involving the sharingof income or assets.

The intent of this disclosure is not to prevent a speaker with commercial affiliations from presenting, but rather to informUniversity Health System of any professional, personal or financial relationships so that conflicts can be resolved prior to theactivity.

Name: «FIRST» «LAST», «DEGREE»

For all disclosures, complete each section, sign and date the last page. Please spell out all acronyms.

I or an immediate family member, have a professional, personal or financial interest/arrangement or affiliation with one or moreorganizations that could be perceived as a real or apparent conflict of interest in the following categories:

1. Employment

□ No, I do not have an employment relationship with a commercial interest to disclose.

□ Yes, I have an employment relationship with

2. Board of Directors/Other Leadership Position

□ No, I do not have a leadership position with a commercial interest to disclose.

□ Yes, I have a leadership relationship with

3. Research Funding

□ No, I do not have research funding from a commercial interest to disclose.

□ Yes, I receive research funding from

4. Paid Consultant or Member of an Advisory Board or Review Panel

□ No, I do not have a consultant or advisory position to disclose.

□ Yes, I have a consultant or advisory board relationship with

5. Speaker’s Bureau

□ No, I am not on a speaker’s bureau for a commercial interest.

□ Yes, I am on the speaker’s bureau(s) for

6. Major Stock or Investment Holder



□ No, I do not have major stock or investment holdings to disclose.

□ Yes, I have stock holdings with

7. Other Remuneration

□ No, I do not have other compensation to disclose.

□ Yes (please list relationship and company name)

Signature of Person Disclosing: ___________________________________Date: ______________

FDA APPROVED DRUG AND DEVICES ASSURANCE STATEMENT

University Health System is required by the TNA and ANCC COA guidelines to instruct you that any discussionsregarding the utilization of FDA approved drugs or devices must be within approved regulations. If you discuss the

utilization of FDA drugs or devices that are outside approved regulations (off-label or investigational uses), you mustclearly delineate this for your audience.

________________________________________________________________Date: ______________ Signature/acknowledgement of Faculty/Content Specialist Disclosing:

For University Health System Nurse Planner use Only:

□ No relevant relationship(s) to resolve □ Session will be monitored to ensure

conflict does not arise

□ The conflict was discussed with the individual □ Provided talking points/outline

□ Restricted presentation to clinical data □ Data, slides added or removed

□ Reassigned faculty’s lecture/topic □ Reviewed content – free of

sponsorship/commercial bias

Notes: _______________________________________________________________________

Signature of Nurse Planner: ______________________________________ Date: ______________



Sample Provider–Directed Evaluation Tool Format

Title of Education Activity: ________________________________________________________________________________ Location: _________________________________________ Date: ___________________________

Learning Goal/Purpose Statement: include the learning goal/purpose statement here or in item #4

below.

Please complete this evaluation questionnaire. Your anonymous responses will be used to revise thisactivity and to plan future educational activities. Circle the number that best fits your evaluation of thisactivity.

1 = Not at all 2 = Somewhat 3 = Almost completely 4 = Completely

Or Rating Scale of Your Choice

1. Rate your achievement of these objectives:a. (State objective from ED form) 1 2 3 4b. (State objective from ED form) 1 2 3 4c. (State objective from ED form) 1 2 3 4

Repeat for all objectives

2. Rate the expertise/effectiveness of each individual faculty?a. (State name of faculty) 1 2 3 4b. (State name of faculty) 1 2 3 4

Repeat for all faculty

3. Were the teaching methods/strategies effective? 1 2 3 4

4. Were the objectives relevant to the overall purpose? 1 2 3 4

5. Were the physical facilities appropriate? 1 2 3 4

6. List two (2) ways you will integrate what you learned in this activity into your practice and/or employment environment.

7. The following were disclosed prior to the beginning of this activity either in writing or verbally?a. Requirements for successful completion Yes Nob. Conflicts of Interest Yes Noc. Resolution of Conflicts of Interests Yes Nod. Sponsorship or Commercial Support Yes Noe. Non-endorsement of Products Yes Nof. Off-label Use Yes No

8. Did you, as a participant, notice any bias that was not previouslydisclosed in this presentation? Yes NoIf “Yes”, please describe who was biased and how.

_________________________________________________________________________________

Comments: (If you answered (1) to any of the above, please comment.)

You may ask additional questions, i.e., more information on speakers or facilities, to identify future topics, as you

desire.



Sample Learner–Paced Evaluation Tool Format

Title of Education Activity: _________________________________________________________________________________ Learning Goal/Purpose Statement: include the learning goal/purpose statement here or in item #4below.

Please complete this evaluation questionnaire. Your anonymous responses will be used to revise thisactivity and to plan future educational activities. Circle the number that best fits your evaluation of thisactivity.

1 = Not at all 2 = Somewhat 3 = Almost completely 4 = Completely

Or Rating Scale of Your Choice

1. Rate your achievement of these objectives:a. (State objective from ED form) 1 2 3 4b. (State objective from ED form) 1 2 3 4c. (State objective from ED form) 1 2 3 4

Repeat for all objectives

2. Rate the effectiveness of the teaching/learning resources? 1 2 3 4

3. Were the objectives relevant to the overall purpose? 1 2 3 4

4. How long in minutes did it take you, learner to complete the activity?_________________________

5. List two (2) ways you will integrate what you learned in this activity into your practice and/or employment environment.

6. The following were disclosed prior to the beginning of this activity either in writing or verbally?a. Requirements for successful completion Yes Nob. Conflicts of Interest Yes Noc. Resolution of Conflicts of Interest Yes Nod. Sponsorship or Commercial Support Yes No

e. Non-endorsement of Products Yes Nof. Off-label Use Yes Nog. Expiration Date Yes No

7. Did you, as a participant, notice any bias that was not previouslydisclosed in this presentation? Yes NoIf “Yes”, please describe who was biased and how.

_________________________________________________________________________________

Comments: (If you answered (1) to any of the above, please comment.)

Date completed: ___________________________

You may ask additional questions, i.e., more information to identify future topics, as you desire.



Sample Commercial Support Agreement

Date: _________________

Parties Involved in Agreement:Approved Provider name and representative’s name :Co-provider’s name (if applicable):

Entity providing commercial support’s name:

The CNE activity entitled ____________________________________________ will bepresented by (Approved Provider Name) and (Co-provider’s name(s) if applicable) on (Date)At (Location).

(Commercial Support Entity’s Name)Will provide: (LIST)

The (Commercial Support Entity’s Name) will be recognized as providing commercial supportin the advertising.

The (Commercial Support Entity’s Name) will in no way influence or bias the content of the CEpresentation. According to commercial support standards as listed in Appendix B of the 2009Application Manual – Accreditation Program, ANCC, the following must be met:

Standard 3: Appropriate Use of Commercial Support

3.1 The provider must make all decisions regarding the disposition and disbursement of commercial support.

ANCC defines “commercial support” as financial, or in-kind, contributions given by acommercial interest, which is used to pay all or part of the costs of a continuing nursingeducation activity.

ANCC does not consider providers of clinical service directly to patients to becommercial interests.

3.2 A provider cannot be required by an entity with a commercial interest to accept adviceor services concerning teachers, authors, or other education matters, including content,from the entity as conditions of contributing funds or services.

3.3 All commercial support associated with a continuing nursing education activity must begiven with the full knowledge and approval of the provider.

Written Agreement Documenting Terms of Support

3.4 The terms, conditions, and purposes of the commercial support must be documented ina written agreement with the entity that includes the provider and its educational

partner(s). The agreement must include the provider, even if the support is givendirectly to the provider’s educational partner or a co-provider.

3.5 The written agreement must specify the entity that is the source of commercial support.

3.6 Both the entity and the provider must sign the written agreement regarding the supportto be provided/accepted.

Expenditures for an individual providing continuing nursing education

3.7 The provider must have written policies and procedures governing honoraria andreimbursement of out-of-pocket expenses for planners, teachers, and authors.



3.8 The provider, the co-provider, or designated educational partner must directly pay anyteacher or author honoraria or reimbursement of out-of-pocket expenses in compliancewith the provider’s written policies and procedures.

3.9 No other payment shall be given to the director of the activity, planning committeemembers, teachers, or authors, co-provider, or any others involved with the supportedactivity.

3.10 If teachers or authors are listed on the agenda as facilitating or conducting apresentation or session, but participate in the remainder of an education event as alearner, their expenses can be reimbursed and honoraria can be paid for their teacher or author role only.

Expenditures for learners

3.11 Social events or meals at continuing nursing education activities cannot compete with,or take precedence over, the educational events.

3.12 The provider may not use commercial support to pay for travel, lodging, honoraria, or personal expenses for non-teacher or non-author participants of a continuing nursingeducation activity. The provider may use commercial support to pay for travel, lodging,honoraria, or personal expenses for bona fide employees and volunteers of theprovider, co-provider or educational partner. This element applies only to nurseswhose official residence is in the United States.

Accountability

3.13 The provider must be able to produce accurate documentation detailing the receipt andexpenditure of commercial support.

Standard 4: Appropriate Management of Associated Commercial Promotion

Commercial exhibits and advertisements are promotional activities and not continuing nursingeducation. Therefore, monies paid by commercial interests to providers for these promotionalactivities are not considered “commercial support.” However, approved providers are expectedto fulfill the requirements of Standard 4, and to use sound fiscal and business practices withrespect to promotional activities.

4.1 Arrangements for commercial exhibits or advertisements cannot influence planning or interfere with the presentation, nor can they be a condition of the provision of commercial support for continuing education activities.

4.2 Product-promotion material or product-specific advertisement of any type is prohibitedin or during continuing nursing education activities. The juxtaposition of editorial andadvertising material on the same products or subjects must be avoided. Live (staffedexhibits, presentations) or enduring (printed or electronic advertisements) promotionalactivities must be kept separate from continuing nursing education.

• Print, advertisements and promotional materials shall not be interleafed withinthe pages of the continuing nursing education content. Advertisements andpromotional materials may face the first or last pages of printed CNE content aslong as these materials are not related to the continuing nursing education contentthey face and are not paid for by the entities with commercial interests in thecontinuing nursing education activity.• Computer-based, advertisements and promotional materials shall note bevisible on the screen at the same time as the continuing nursing education contentand shall not be interleafed between computer “windows” or screen of thecontinuing nursing education content.



• Audio and video recording, advertisements and promotional materials shallnot be included within the continuing nursing education. There will be no“commercial breaks.”• Live face-to-face continuing nursing education, advertisements andpromotional materials shall not be displayed or distributed in the educational spaceimmediately before, during, or after a continuing nursing education activity.Providers shall not allow representatives of an entity with commercial interests toengage in sales or promotional activity while in the space or place of the continuingnursing education activity.

4.3 Educational materials that are part of a continuing nursing education activity, such asslides, abstracts, and handouts, shall not contain any advertising, trade name, or aproduct-group message.

4.4 Print or electronic information distributed about the non-continuing nursing educationelements of a continuing nursing education activity that are not directly related to thetransfer of education to the learner, such as schedules and content descriptions, mayinclude product promotion material or product-specific advertisement.

4.5 A provider shall not use an entity with a commercial interest as the agent providing a

continuing nursing education activity to learners, e.g., distribution of self-studycontinuing nursing education activities or arranging for electronic access to continuingnursing education activities.

Standard 5: Content and Format Without Commercial Bias

5.1 The content or format of a continuing nursing education activity or its related materialsmust promote improvements or quality in health care and not a specific proprietarybusiness interest of an entity with a commercial interest.

5.2 Presentations must give a balanced view of therapeutic options. Use of generic nameswill contribute to this impartiality. If the continuing nursing education educationalmaterial or content includes trade names, when available, trade names from several

companies should be used, not just trade names from a single company.

The signatures below by representatives from each organization listed above indicate agreement with theabove statements.

Provider Representative:(Signature above) Date above

Print Name:Title:

Co-Provider Representative:(Signature above) IF APPLICABLE Date abovePrint Name:Title:

Commercial Support Entity:(Signature above) Date abovePrint Name:Title:

SAMPLE SPONSOR AGREEMENT

Date: _________________



Parties Involved in Agreement:Approved Provider name and representative’s name :Co-provider’s name (if applicable): Sponsor’s name:

The CNE activity entitled ____________________________________________ will be presented by(Approved Provider Name) and (Co-provider’s name(s) if applicable) on (Date)At (Location).Sponsor’s name: will provide:

(LIST)

Sponsor’s name will be recognized as a sponsor in the advertising. They have not been nor will beinvolved in the planning, implementation or evaluation of this activity. The sponsor or sponsorship itemswill in no way be allowed to influence or bias the content of the continuing nursing education presentation.The signatures below by representatives from each organization listed above indicate agreement with theabove statements.

Provider Representative:(Signature above) Date above

Print Name:Title:

Co-Provider Representative:(Signature above) IF APPLICABLE Date abovePrint Name:Title:

Sponsor:(Signature above) Date abovePrint Name:Title:



Disclosure to Participants ______________________________________________________

(University Health System)Accreditation Statement:(University Health System) is an approved provider of continuing nursing education by the TexasNurses Association, an accredited approver by the American Nurses Credentialing Center’s Commissionon Accreditation.

Disclosures to Participants

____________________________________________________________________________ (Title of educational activity)Requirements for Successful Completion:The learning goal/purpose of this educational activity is: _______________________________

____________________________________________________________________________

____________________________________________________________________________

The objectives of this education activity are: (add as many lines as necessary)

1.

2.

3.

4.

To receive contact hours for this continuing education activity, the participant must:•

•

•

Once successful completion has been verified, a “Certificate of Successful Completion” will be awardedfor __________ contact hours.Conflicts of Interest:Explanation: A conflict of interest occurs when an individual has an opportunity to affect or impact educationalcontent with which he or she may have a commercial interest or a potentially biasing relationship of a financial,professional or personal nature. All planners and faculty/content specialist(s) must disclose the presence or absence of a conflict of interest relative to this activity. All potential conflicts are resolved prior to the planning,implementation, or evaluation of the continuing nursing education activity. All activity planning committee membersand faculty/content specialists have submitted Conflict of Interest Disclosure forms.

[The planning committee members and faculty/content specialists of this CNE activity have disclosed norelevant professional, personal or financial relationships related to the planning or implementation of thisCNE activity.]

OR[The planning committee members and faculty/content specialists of this CNE activity have disclosed thefollowing relevant professional or personal financial relationships related to the planning or implementation of this CNE activity

• __________________________________ ________________________________ (Person’s name) (Company)

__________________________________ _________________________________ (Conflict) (Resolution)

• __________________________________ ________________________________ (Person’s name) (Company)

__________________________________ _________________________________ (Conflict) (Resolution)

Sponsorship or Commercial Support:[This CNE activity received no sponsorships or commercial support.]

OR[This CNE activity has received the following sponsorship(s) and/or commercial support:



• _____________________________ _______________________________

(Company) (Type of Support)

• _____________________________ _______________________________ (Company) (Type of Support) ]

Non-Endorsement of Products:Approved provider status of (University Health System) refers only to the continuing nursingeducation activity and does not imply a real or implied endorsement by (University Health System) theAmerican Nurses Credentialing Center (ANCC) or the Texas Nurses Association (TNA) of anycommercial product, service, or company referred to or displayed in conjunction with this activity, nor anycompany subsidizing costs related to this activity.Off-label Product Use:[This CNE activity does not include any information about off-label use of any product for a purpose other than that for which it is approved by the U.S. Food and Drug Administration (FDA).]

OR[This CNE activity will include information about the off-label use of the following product(s):

•

•

• ]

Expiration Date for Awarding Contact Hours: (Include only if this educational activity is a learner-paced activity).This activity expires _________________________________.

Reporting of Perceived Bias:Bias is defined by the American Nurses Credentialing Center’s Commission on Accreditation (ANCCCOA) as preferential influence that causes a distortion of opinion or of facts. Commercial bias may occur when a CNE activity promotes one or more product(s) (drugs, devices, services, software, hardware,etc.) This definition is not all inclusive and participants may use their own interpretation in deciding if apresentation is biased.

The ANCC COA is interested in the opinions and perceptions of participants at approved CNE activities,especially in the presence of actual or perceived bias in continuing education. Therefore, ANCC invitesparticipants to access their “ANCC Accreditation Feedback Line” to report any noted bias or conflict of

interest in the educational activity. The toll free number is 1(866) 262-9730.Attestation:If any or all of the above information was disclosed verbally to participants, a representative of the CNEApproved Provider Unit must attest that the disclosure did occur.I, ____________________________, attest that the above information was disclosed to the continuingnursing education activity participants.

______________________________________________ ___________________ Signature Date

TNA Application April 2010

Documents

Transcript of TNA Application April 2010