Individual Activity Application

Individual Activity Application Form Template Revised 08.25.2016

__

For Office Use Only Date

Received:

Amount Received:

Credit Card:

Check Number:

A-CNE: #______________

ELECTRONIC copy of the application must:

Use WSNA A-CNE forms only Have a table of contents; Pages numbered consistent with the table of contents; Electronically submit one complete application packet and

payment based on number of projected contact hours orwhichever is greater for the fee to kmacleod@wsna.org

CAUTION: WSNA-A-CNE guidelines/forms are periodically updated; therefore, check that you are using the most current Revised Guidelines located on the WSNA A-CNE website: http://www.wsna.org/Education/A-CNE/Forms/Faculty-Directed/

PLEASE NOTE THAT TO ASSIST YOU SHOULD YOU WISH TO APPLY FOR AN APPROVED PROVIDER STATUS CRITERIA (NUMBERS/LETTERS) ARE NEXT TO THE CRITERIA YOU WILL USE TO WRITE THE APPROVED PROVIDER APPLICATION.

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.

If no, this activity is not eligible for approval.

I authorize inclusion of this CNE activity in the published WSNA CNE calendars.

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

Applicant' s Name, title and credentials:

Washington State Nurses Association (WSNA) Approver of Continuing Nursing Education (A-CNE)

Individual Educational Activity Application 2015 Criteria (current)

AA/IA-App

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Individual Activity Application Form Template Revised 08.25.2016

Individual Activity Application

Criterion 1: Structural Capacity

A. Provider Demographics:a. _____________________________________________________________

Name of Organization:b. _______________________________________________________________________________

Organization Address: City State Zip/Postal Country

c. Identify Organization Type:

Constituent Member Associations of ANA

College or University

Healthcare Facility

Health - Related Organization

Multidisciplinary Educational Group

Professional Nursing Education Group

Specialty Nursing Organization

Other: ___________________________________________________________________

d. Title of Activity:________________________________________________________________

e. Date Form Completed: ___________________________

f. Number of contact hours requested: _______________

g. Activity Type:

Provider-directed, provider-paced: Live (in person or webinar)

o Date of live activity: __________________

Provider-directed, learner-paced: Enduring material

o Start date of enduring material: ___________________

o Expiration/end date of enduring material: ___________

Blended activity

o Date(s) of enduring materials (e.g. prework): ________

o Date of live portion of activity: ___________________

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Fee to be charged for course: _____

Learner-directed, learner-paced: (Must have Nurse Planner Oversite)

o

o

Date of live portion of activity: ___________________

Name of Nurse Planner Supervising Activity: ___________________

Indi vidual Activity Application Form Template Revised 08.25.2016

Individual Activity Application h. Activity Contact (Must be a Nurse Planner for this activity otherwise review will not proceed

and application will not be accepted):

Name, degree, and credentials: ________________________________________________

Note: Nurse Planner (NP) must be a currently licensed registered nurse with a baccalaureatedegree or higher in nursing, is responsible for adherence to ANCC & WSNA A-CNE criteria; andbe actively involved in planning, implementing and evaluating this CNE activity.

B. Planning Committee Members

Planners must include a minimum of two individuals:1) The Nurse Planner (NP) with knowledge of ANCC & WSNA A-CNE CNE criteria andprocess and,2) One other planner with relevant content expertise. (The second planner does not have to be anRN.)

Other Committee members may include: • Faculty/Presenters/Authors• Other Nurse Planners• Feedback Personnel (for

Independent Studies)

Note: A Content Reviewer is not included on the planning committee. The purpose of a content reviewer is to evaluate a speaker(s) in an educational activity during the planning process or after it has been planned but prior to delivery to learners, for quality of content, potential bias, and COI.

a. Nurse Planner

Name, degree(s),credential(s):_______________________________________________________

Daytime Phone number: ____________________ Ext. _________ E-mail: _________________________________ FAX Number: _____________________

Bio&COI Data Form (completed, dated, signed) is attached. Page ____

b. Content Expert Planner

Individual has relevant content expertise for the activity being offered. (Does not have to be an RN)

Name, degree(s), credential(s):__________________________________________________

Each Planner must complete a BIO/COI Data Form (AA/IA-BIO/COI). Instructions:

• List the name, degrees (i.e., BSN, MN), credentials such aslicensure, and/or certifications (i.e., RN, APRN, CNS, CCRN)for every planner.

• Check the appropriate box at top of the Bio Data Form,indicating the respective Planner Role(s) (i.e. NP, Content Expert, Other) and,

• Complete all applicable sections.• The NP MUST evaluate each one for possible conflict of

interest and intervene if warranted.

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Indi vidual Activity Application Form Template Revised 08.25.2016

Individual Activity Application Bio Data Form describes the relevant content expertise of the Content Expert (i.e., education,

experience, certification, publication, research)

Bio & COI Data Form with potential or real or resolution COI (completed, dated, signed)is attached. Page: __

Attachment A: Individuals in Position of Control Content

c. Other Planners (see WSNA attachment A)Complete this table for each person in a position to

control content of the educational activity. There must be a NP and one other planner with expertise

for the educational activity.

List name(s), degree(s), credentials, nature of relationship of all planners

ci. Content Reviewer (Optional Role and not included on the planning committee.

Does this activity have a Content Reviewer? Yes ___ No ___

If yes, list name, degree(s), Credential(s): _______________________________________

Bio &COI Data Form(s) with potential or real COI (completed, dated, signed) is attached.

Criterion 2: Educational Design Process

A. Assessment of Learner NeedsWhich needs assessment method(s) and supporting needs data were used to plan this activity?

NOTE: Evidence of needs assessment data sources and findings must be retained in the activity file and beavailable to WSNA A-CNE upon request.

Identify the applicable missing gap(s): the difference (gap) between actual and desired knowledge,skills, practice that will be addressed by this educational activity. This is based upon analysis of theneeds assessment data. (Only address those gaps that are applicable for this activity.)

a. Describe the learner’s current state. What is the problem? (EDP1)

b. Describe the desired state:

c. Identified gap:

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Indi vidual Activity Application Form Template Revised 08.25.2016

Individual Activity Application B. Evidence to Validate the Professional Practice Gap (check all methods/types of data that apply)

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:

a. Please Provide a Brief Summary of Data Gathered that Validates the Need for this Activity:

C. Educational Need that Underlies the Professional Practice Gap (e.g. knowledge, skill and/orpractices) (EDP2) Gap In Knowledge (knows) Gap in Skills (knows how) Gap in Practice (shows/does Other (Describe):

D. Description of the Target Audience (check all that apply):

All RNs Advance Practice RNs RNs in Specialty Area: (Identify Specialty): _________________________________________ LPNs Interprofessional (Describe): _____________________________________________ Other (Describe): _______________________________________________________

E. Desired learning Outcome(s): (What will the outcome be as a result of participation in this activity?)What is the desired learning outcome for the learner? What should the nurse be able to do orachieve after participating in this event? (Be sure this is congruent with A through D above.)

a. Area of Impact (check all that apply): Nursing Professional Development Patient Outcome Other – Describe: ____________________________________________________________

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Individual Activity Application F. Outcome Measure (A quantitative statement as to how the outcome will be measured):

a.

Contact hours are awarded to participants for those portions of the educational activity devoted to didactic or clinical experience and to evaluating the activity. The appropriate measure of credit is the 60-minute contact hour. If rounding is desired in the calculation of contact hours, the provider must round down to the nearest 1/10th or 1/100th (e.g., 2.758 should be 2.75 or 2.7, not 2.8). They may not be rounded up!Educational activities may also be conducted asynchronously and contact hours awarded at the conclusion of the activities.Time frames must match and support the contact hour calculation for live activities. Evidence may include, but is not limited to, agenda for the activity, outline of content to be delivered in the activity, and/or other marketing materials. Time for breaks and meals should be clearly delineated and not included in total contact hours awarded. For enduring materials such as print, electronic, web-based, etc., the emthod for cacluating the contact hours must be identified. The method may include, but is not limited to, a pilot study, historical data, or completity of content.Criteria for Awarding Contact Hours (Consistent with outcome, content, and learning strategies).

Check all that apply:

Attendance for a specified period of time (e.g., 100% of activity, or miss no more than 10

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G. Content of Activity. (A description of the content with supporting references or resources (EDP4)

Activity Education Planning Table Form

H. Content for this Educational Activity was Chosen From (references should be within past 5-7 years):

Information available from the following organization/web site:

Information available through peer-reviewed journal/resources: Clinical Guidelines (e.g. – www.guidelines.gov):

Expert Resource (Individual, organization, educational institution, book, article):

Textbook Reference:

Other:

I. Learner engagement strategies (EDP5):

See Gap Analysis and Educational Planning form OR

Integrating Opportunities for dialgue or question/answer:

Including time for self-check or reflection

Analyzing case studies

Providing Opportunities for problem-based learning

Other:

J. Criteria for Awarding Contact Hours (Consistent with the outcomes, content and learningstrategies)

Individual Activity Application Form Template Revised 08.25.2016

Individual Activity Application Form Template Revised 08.25.2016 7

Credit awarded commensurate with participation

Attendance at 1 or more sessions

Completion/Submission of evaluation form

Successful completion of post test (e.g. attendee must score ____% or higher)

Successful completion of a return demonstration

Other – Describe:

b. Independent Study Activity. How were the contact hours calculated (Check the bestdescription that applies):

Pilot Study Historical Data Mergener Formula Other: Describe:

Note: Identify Pharmacotherapeutic minutes or hours if the activity is for APRNs and the content relates to pharmacotherapeutics. (Refer to the Guidelines for more information.)

c. Show Evidence of How Contact Hours Were Calculated (i.e., 240/60 = 4 contact hours)

K. Evaluation. Check the method(s) of Evaluation (EDP6 & 7) a. Short-Term Evaluation Options:

□ Active participation in learning activity□ Post-test□ Return demonstration□ Case study analysis□ Role-play□ Other – Describe:

□ Copy of Evaluation attached. Page:

b. Long-Term Evaluation Options:

□ Self-reported change in practice□ Change in quality outcome measure

Individual Activity Application Form Template Revised 08.25.2016

Individual Activity Application

□ Return on Investment (ROI)□ Observation of performance□ Other – Describe: ________________________________________________________

NOTE: A copy of a summative evaluation must be kept in the activity file for six years. A summative evaluation is the compilation of the results of the learners’ comments in a statistical format and a listing of all comments made by the learners. E.g.: if ten participants stated they met outcome 1, you would insert the number

L. Quality Improvement Process or Form for End of Activity.

Copy of QI attached. Page: __

M. Commercial Support:A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, ordistributing healthcare goods or services consumed by, or used on, patients or an entity that isowned or controlled by an entity that produces, markets, re-sells or distributes healthcare goodsor services consumed by, or used on, patients. Exceptions are made for non-profit or governmentorganizations and non-healthcare related companies.

- Commercial Support is financial or in-kind contributions given by a commercial interestthat are used to pay for all or part of the costs of a CNE activity

- A provider of commercial support may not be on an educational planning committee, bea joint-provider of the activity, or the provider of the activity.

- If commercial support is provided for a CE activity, an employee from the organizationproviding commercial support may not be a speaker.

□ This activity has no commercial support.□ Commercial support has been provided by the following: (List name of

organization(s):______________________________________________________________□ Signed commercial support agreement attached. Page: ___

N. Joint-Providership

□ This activity will not be jointly provided, OR□ Joint providership of this activity has been arranged with: (List organization name):

□ As the educational provider, we will maintain responsibility for adherence to criteriafor this activity

□ Our name as the educational provider and the names of the joint providers will beprominently listed in advertising.

□ The signed, dated, written joint-provider agreement is attached. Page: __

Note: You are not required to have a commercial support agreement for those who are only exhibiting at the event.

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Individual Activity Application Form Template Revised 08.25.2016

Individual Activity Application

O. Advertising:Check all that apply: Attach a copy of each one checked including relevant pages off the website (if applicable)

Flyer/brochure. Attached Page: ___ Memo/letter Attached Page: ___ E-mail Attached Page: ___ Website Attached Page: ___ Social media Attached Page: ___ Other – Attached Page: ___

Describe: __________________________________________________________

P. Written Disclosures Provided to Activity Participants.Learners must receive written disclosure of required items prior to beginning the learning activity. (Ifa disclosure is provided verbally, an audience member must document both the type of a disclosureand the inclusion of all required disclosure elements. )The following are required on ALL Disclosures:

□ Criteria for successful completion;□ Presence of conflict of interest for planners, presenters, faculty, authors and content

reviewers. Must disclose name of individual, name of commercial interest, and natureof the relationship the individual has with the commercial interest;

□ Approved provider statement (see sample below);

b. Include the following in relevant situations:□ Commercial support, if applicable (name of each supporter and nature of support);□ Joint Providers, if applicable (name of each provider);□ For independent study only include the expiration date for awarding contact hours

NOTE: Select the appropriate Approved Provider Statement

Prior to Approval (If contact hours are mentioned) This activity has been submitted to the Washington State Nurses Association Approver of Continuing Nursing

Education (A-CNE) for approval to award contact hours. The Washington State Nurses Association Approver of Continuing Nursing Education (A-CNE) is accredited as an approver of continuing nursing education by the

American Nurses Credentialing Center’s Commission on Accreditation.

Post Approval: All promotional/advertising material must include the following statement once application has been approved and contact hours are listed:

This continuing nursing education activity was approved by the Washington State Nurses Association Approver of Continuing Nursing Education (A-CNE), an accredited approver by the

American Nurses Credentialing Center’s Commission on Accreditation

□ The disclosure is attached. Page: ___

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Individual Activity Application Form Template Revised 08.25.2016

Individual Activity Application

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Q. Documentation of completion. Document/certificate must include:

□ Name of learner□ Name and address of Approved Provider Unit (web address acceptable)□ Title & date of completion of educational activity□ Number of contact hours awarded□ Official Approved Provider Unit statement (see below) □ Include pharmacotherapeutic hours if applicable (e.g., 4 contact hours including 1.5

Pharm contact hours)□ A copy of the certificate is attached. Page: ____

R. Recordkeeping and Storage System: All correspondence, a complete copy of the application form and all attachments and corrections, records of attendance, summative evaluation(s), contact hours and other items listed in the Guidelines for this activity will be maintained in a retrievable file (electronic) accessible to authorized personnel for six years.

□ Attachment B: WSNA-A-CNE checklist activity