web view☐national nurses’ organizations ... (math calculation) ... undertaking review of the...

L O U I S I A N A S T A T E N U R S E S A S S O C I A T I O N I S A C C R E D I T E D A S A N A P P R O V E R O F C O N T I N U I N G N U R S I N G E D U C A T I O N B Y T H E A M E R I C A N N U R S E S C R E D E N T I A L I N G C E N T E R ’ S C O M M I S S I O N O N A C C R E D I T A T I O N .

Individual Educational Activity Application

The LSNA Approver Unit is accredited as an approver of continuing nursing education (CNE) by the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation (COA) and adheres to the criteria established by the ANCC-COA.

IEA Applicants of continuing nursing education (CNE) who participate in the approval process are expected to document compliance with all Provider and Educational Design Criteria.

Read all instructions carefully, if you have any questions or concerns contact CNE Coordinator.

DIRECTIONS:ALL SUBMISSIONS are required to be, this includes later revisions as well,...

On the current forms, which can be found at www.lsna.org Done electronically & typed; mailed, faxed, and handwritten entries will NO longer be accepted.

Check Boxes Highlight (yellow) can be used for making a selection as well.

In WORD or PDF (For purpose of this review only: PowerPoint and Excel file examples need to be converted to PDF) Clearly labeled and…

o Emailed to [email protected] Subject Line: Title of Activity – APPLICATION

ORo Mailed to LSNA on a flash drive or cd (see below under PAYMENT for address)

APPLICATION: 1. Required to be received at least 60 DAYS before the date of the activity fully completed.

(no retroactive approval is ever allowed) See payment form for late fees (20 DAYS BEFORE WILL NOT BE ACCEPTED).

If you are not certain of the date, state when it might be scheduled in the future Example: To be scheduled “once approval received” or “after mm/dd/yy [In future]”

Remember to notify LSNA in writing once the date is scheduled. 2. Some of the information will be typed directly on the form; others will be documents you attach. Attached information is

required to be clearly labeled and titled in accordance with the outline, divided clearly, and numbered in sequence. If more space is needed than provided, in any section, clearly identify where to find continuation.

3. Live vs. Enduring Activities – No longer have separate forms. 4. Documents and instructions related to the application are located in the Samples and Resources sections on the website.

If the activity is approved, it can be presented as often as desired during the two-year approval period as stated on the approval letter unless substantial changes are made.

CHANGES: 1. A speaker, nurse planner, or planning committee member can be changed after approval but not the presentation content.

a. Submit an updated BIO & Conflict Form for the nurse planner or planning committee member FOR REVIEW.2. A new sponsor can be submitted at any time (even after approval) with the correct documents to the CNE coordinator for

review, before the IEA is given.

PAYMENT: 1. The IEA Payment Form has the fees for the review process. Applications will not be considered complete unless payment

(with form) has been received; must be with but separate from the application.2. Payment is for the review process ONLY; once the process has started no refunds will be given for denial or withdrawal. 3. Checks (if paying by) - mail to LSNA with a copy of the Payment Form for reference.

a. Do not forget to factor in the time it will take for YOUR organization to process payment and send.

Payable: LSNAMail to: 543 Spanish Town Rd Baton Rouge, LA 70802

It is suggested the applicant put the Nurse Peer Review Leader email on the safe sender list:[email protected]

Individual Activity Application, 2015 criteria, 12/2016 of 16

mailto:[email protected]

http://www.lsna.org/


IEA APPLICATION CHECKLIST

A completed application includes the following:

☐1 electronic copy of the completed Individual Educational Activity Application Packet☐1 electronic copy of the completed PAYMENT FORM (with but separate from application)

Individual Educational Activity Application Packet includes:☐ IEA Application (THIS FORM)☐Attachment 01: Gap Analysis Worksheet☐Attachment 02: Educational Planning Table

(DO NOT SEND SLIDES OR HANDOUTS)☐Attachment 03: Evaluation Form☐Attachment 04: Biographical & Conflict of Interest Form (for Nurse Planner & Content Expert)

(DO NOT SEND CVS OR RESUMES)☐ Attachment 05: Agenda ☐Attachment 06: Advertising materials ☐Attachment 07: Commercial Support Agreement(s)*☐Attachment 08: Disclosure Communication☐Attachment 09: Certificate of Successful Completion☐Attachment 10: Commercial Interest Addendum*(If necessary)

*This form may not be applicable to your application.



Applicant Eligibility Verification Applicants interested in submitting an individual educational activity for approval must complete the

Eligibility Verification Form and meet all Eligibility Requirements. Verification forms received from applicants that do not meet Eligibility Requirements will be rejected without substantive review.

Section 1: Eligibility Applicant/Organization:

Name:Email: Web Address:

Address/City : State: ZIP:

Identify Organization Type: ☐Constituent Member Association of ANA ☐College or University☐Healthcare Facility (includes home health, hospice, etc.)

☐Health Related Organization ☐Multidisciplinary Education Group☐Specialty Nursing Organization ☐Other

If other: Describe Click here to describePrimary Contact Person:

Name: Title/Position:Email: Phone: EX:

A. Has the applicant ever been denied accreditation by ANCC or had its accreditation status suspended or revoked? ☐Yes ☐No

If yes, please provide the following information: Action: ☐Denial ☐ Suspension ☐ RevocationDate: Click here to enter a date.Brief description: Click here to Describe

B. Has the applicant ever had approval denied, suspended, or revoked for an Individual Educational Activity or Approved Provider application by any ANCC Accredited Approver? ☐Yes ☐No

If yes, please provide the following information: Action: ☐Denial ☐ Suspension ☐ RevocationName of Organization Issuing: Click here to enter a date. Date: Click here to enter a date.Brief description: Click here to Describe

C. A currently licensed registered nurse, with a baccalaureate degree or higher in nursing, is actively involved as the Nurse Planner in the planning, implementing, and evaluation process of this continuing education activity: ☐Yes ☐No

List the name and credentials of the nurse(s) involved/responsible for this educational activity:Nurse Planner Name &

Credentials Email Nursing License #/State

(tab in last box for more space)

Section 2: Commercial InterestThe following section is intended to collect information about the applicant's corporate structure.

A. ☐ An "X" on this line identifies the applicant type as automatically exempt from ANCC’s definition of a commercial interest.Identify the applicant's exemption type below:

☐Blood banks☐Constituent Member Associations☐Diagnostic laboratories☐Federal Nursing Services☐For-profit & not for profit hospitals ☐ For-profit & not for profit nursing homes ☐For profit & not for profit rehabilitation centers ☐Group medical practices☐Government organizations

☐Health insurance providers ☐Liability insurance providers☐National nurses’ organizations

(based outside the United States) ☐Non-health care related companies☐Specialty Nursing Organizations☐A single-focused organization

(exists for the single purpose of providing CNE)

501c applicants are not automatically exempt.



The ANCC Accreditation Program requires 501c applicants to be screened for eligibility.

If you checked the box above, you have completed this questionnaire, proceed to Section 4.

**Only complete section B if applicant organization is NOT exempt**B. An "X" on this line identifies the applicant as not exempt from the ANCC Accreditation Program’s

definition of a commercial interest.

The following questions must be answered to properly assess the applicant's eligibility:

1. Does the applicant produce, market, re-sell, or distribute health care goods / services consumed by, or used on, patients? ☐Yes If yes, the applicant is not eligible for approval of Individual Educational Activities.☐No If no, complete the next bulleted question

2. Is the applicant owned or controlled by a multi-focused organization (MFO*) that produces, markets, re-sells, or distributes health care goods / services consumed by, or used on, patients? ☐Yes If yes, complete the next bulleted question☐No If no, this section of the questionnaire is complete, proceed to Section 4.

3. Is the applicant a separate and distinct entity from the MFO*?☐Yes If yes, continue to section 3☐No If no, the applicant is not a separate and distinct entity from the MFO* then the applicant is not

eligible for approval of Individual Education Activities.

* Multi-Focused Organization (MFO) is an organization that exists for more than providing continuing nursing education.

Section 3: Commercial Interest EvaluationA. Does the MFO that owns the applicant have a 501-C Non-profit Status?

☐Yes ☐No If no, complete section B.

If yes, does the company that owns the applicant advocate for a commercial interest (as defined by the ANCC Accreditation Program?)☐Yes If yes, or not sure, please describe the relationship the company that the applicant has with a

commercial interest and the types of work the company that owns the applicant does for or on behalf of a commercial interest that might be considered advocacy. Click here to enter text.

☐No Commercial InterestB. Is any component of the MFO an entity that produces, markets, re-sells, or distributes health care goods /

services consumed by, or used on, patients?☐Yes If yes, please describe the health care good / service consumed by, or used on, patients and the role of

the entity in producing, marketing, re-selling or distributing those healthcare goods / services. Click here to enter text.

☐No If no, this section of the questionnaire is complete, proceed to Section 4.If yes, please complete and submit the

☐ Commercial Interest Addendum Template (Attachment Ten)

If you have any questions about your organizations eligibility

STOP HEREContact the Approver Unit



Section 4: Statement of Understanding DOES THE PLANNED ACTIVITY MEET THE DEFINITION OF CONTINUING NURSING EDUCATION?

A. Does the planned educational activity meet ALL of the following requirements? Content must meet the definition of continuing nursing education1

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 Content must be evidenced-based or based on the best available evidence Activity must be at least 30 minutes in length

☐ YES Please continue to Nurse Planner Attestation.☐ NO This educational activity is not eligible for review.

B. Nurse Planner Attestation (enter organization name): On behalf of Click here to enter text, I hereby attest the information provided on and with this application is true,

complete, and correct. I further attest, by my signature below that Click here to enter text will comply with all eligibility requirements and approval criteria throughout the approval period, and that Click here to enter text will notify the LSNA promptly, if, for any reason while this application is pending or during any approval period, Click here to enter text does not maintain compliance.

I understand any misstatement of material fact submitted on, with, or in furtherance of this application for activity approval shall be sufficient cause for the LSNA to deny, suspend, or terminate approval of this activity and to take other appropriate action against Click here to enter text.

☐ Electronic Signature: An ‘X’ serves as the electronic signature of the individual completing this form, attests to the accuracy of the information given above

☐ and I hereby give LSNA permission to release activity information on the website.

Nurse Planner Name and Credentials (required) Date

1 Continuing nursing education activities are those learning activities 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 the end of improving the health of the public and RNs’ pursuit of their professional career goals.



Demographic Data: Contact Person (person filling out the forms):

Name: Title/Position:Email: Phone: EX:

Organization:Address/City: State: ZIP:

Activity:Title:

Location: # Contact Hours:Address/City: State: ZIP:

Activity Type:

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

DATE of LIVE activity:

☐ Provider-directed, LEARNER-paced: Enduring material (no more than 2 years)

Start DATE Enduring Material:End DATE Enduring Material:

NURSE PLANNER for this activity:Name: Credentials:Email: Phone: EX:

Address/City: State: ZIP:

Educational Design Processes: A. Description of the professional practice gap:

Identify the gap(s) (difference between current state and desired state) in knowledge, skills, or practice revealed by the needs assessment, which the activity was designed to address (i.e. change in practice, problem in practice, and opportunity for improvement).

The planning committee should:1. Use information from the needs assessment to identify the current level of knowledge, skill, or practice of the

target audience.2. Then determine the difference between the prospective participant’s current level of knowledge, skill, or practice

and where it should be; this difference is the ‘problem in practice’ or ‘gap’. a. If the identified gap can be closed by education the educational activity is designed to address the “missing”

knowledge, skill, or practice. The website has a Gap Analysis Worksheet that should be used to identify the Gap, Learning Outcomes and Evaluation Method.

Describe the current state: Click here to enter text.

Describe the desired state: Click here to enter text.

Gap(s) Identified/Described below: at least one gap must be identified and describedGap(s) in Knowledge (does not know): Click here to enter text.

Gap(s) in Skills (does not know how):Click here to enter text.

Gap(s) in Practice (does not show/do in practice):Click here to enter text.

☐ Gap Analysis Worksheet (Attachment One)

B. Evidence to validate the professional practice gap (check all methods/types of data that apply)☐Survey data/written needs assessment 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 activitiesTrends in literature, law and health careTrends in practice, treatments and/or technology☐Other – Describe: Click here to enter text.

Please provide a brief summary of data gathered that validates the need for this activity: Click here to enter text. ☐

C. Indicate the source(s) of supporting evidence for the needs assessment data and professional practice gaps. (Applicants must be able to access and provide this data upon request)

☐Annual needs assessment or survey ☐Literature Review

☐Surveys from stakeholders or learners☐Outcome/Quality Data (i.e. Regulatory)

☐Requests (phone, in person, email)☐Activity evaluation summary requests☐Research findings☐Content expert☐OtherIf other: Describe Click here to enter text

D. Description of the target audience Choose an item. Specify if asked: Click or tap here to enter text.

E. Desired learning outcome(s) – Outcomes are evaluated to determine the impact of educational activities on patient care and professional development of the learner. Specific Outcomes are to be documented on the

☐ Educational Planning Table (Attachment Two)The outcomes will be used to evaluate the educational activity’s impact on (check all that apply):☐Nursing Professional Development ☐ Patient Outcome ☐ Other: Click here to enter text

F. Content of activity: A description of the content with supporting references or resources.

Content for this educational activity was chosen from: Be congruent with purpose and objectives Include details beyond a restatement of objectives Reflect the intent of the objectives Be numbered consistently with the related objective Be evidence-based or based on the best available evidence

Content for this educational activity was chosen from (if you have multiple presenters at an activity – each presenter must identify where content was chosen from). Listed below are some examples:

Information available from the following organization/web site (must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content: Examples: Agency for Healthcare Research and Quality, Centers for Disease Control, and

National Institutes of Health Information available through peer-reviewed journal/resource (reference within past 5 – 7 years) Clinical guidelines (example - www.guidelines.gov) Expert resource (individual, organization, educational institution) Textbook reference (book, article, web site)

(List references on the Educational Planning Table)G. Learner engagement strategies

☐ Integrating opportunities for dialogue or question/answer☐ Including time for self-check or reflection☐ Analyzing case studies☐ Providing opportunities for problem-based learning☐ Other – Describe: Click here to enter text.



H. Learner Feedback: Check the best description or describe how learners will be provided feedback.☐ Question and answers during activity☐ Self-check questions☐ Engaging learners in dialogue☐ Return results of testing☐ Return demonstration☐ Role play☐ Other – Describe: Click here to enter text.

I. Criteria for Successful Completion1. Criteria for successful completion for live & enduring material activities include (check all that apply):

☐ Attendance at entire event or session ☐ Credit awarded commensurate with participation☐ Attendance at one (1) or more sessions ☐ Completion/submission of evaluation form ☐ Achieving passing score on post-test (Passing score is: %)☐ Return demonstration ☐ Other – Describe: Click here to enter text.

2. Rationale for method selected above to determine successful completion (check all that apply):☐ Method of evaluation selected☐ Importance of content knowledge☐ Importance of content application ☐ Required by employer or organization ☐ Other – Describe: Click here to enter text.

3. Partial Credit Awarded for Participation?☐ Contact hours awarded based on # of minutes attended ☐ Contact hours awarded for 1/2 day (1/2 of total eligible contact hours) ☐ Contact hours awarded based on # of sessions attended ☐ No partial credit is awarded

J. Verify Participation:☐ Attendance/participation will be verified through sign in sheets/registration form.☐ Signed attestation statement by participant verifying completion of entire or part of the activity.☐ Collection of participation verification via computer log☐ Other – Describe: Click here to enter text.

K. Description of evaluation method: Evidence the change in knowledge, skills and/or practices of target audience was assessed (check all methods/types of data that apply): (If you check Long Term – you will need to identify how you plan to do the evaluation)

Short-term evaluation options: Long-term evaluation options:☐ Intent to change practice☐ Active participation in learning activity☐ Post-test☐ Return demonstration☐ Case study analysis☐ Role-play☐ Other – Describe: Click here to enter text.

☐ Self-reported change in practice☐ Change in quality outcome measure☐ Return on Investment (ROI)☐ Observation of performance☐ Other – Describe: Click here to enter text.☐ Describe how you will conduct a Long Term

Evaluation: Click here to enter text.

☐ Copy of Evaluation Form is attached (Attachment Three)

The Nurse Planner and/or planning committee must review the summative evaluation to assess the activity's effectiveness and to identify how results may be used to guide future educational activities. Identify how summative evaluation results will be used to guide the development of future educational activities:

(check all that apply)

☐ Revisions to subsequent offerings (repeat activities)☐ Provide feedback to participants☐ Shared with planning committee



☐ Shared with presenters/faculty/authors☐ Share with administration/QI staff☐ Future planning of educational activities☐ Other If other: Describe Click here to enter text.

☐ Upon completion of the activity, the summative evaluation is generated.

Summative Evaluation - it is suggested taking a copy of your evaluation document and putting in the totals from your participants completed ones (this included comments).

Example:

Rate your achievement of the learning outcomeAfter completing this session, I am able to:

4Excellent

3Good

2Fair

1Poor

0NA

To apply the principles and practice of mentoring in the work setting. . 26 10 5 2 1

This summary is two (2) attachments.The Post-Activity Documentation (PAD) Form and Summative Evaluation will be

submitted to approver unit within one month after the activity.Both Forms will be online OR sent with Approval Letter / Email.

Awarding Contact Hours:A contact hour is a 60-minute hour.

The contact hour may be taken to the hundredths; but may not be rounded up: i.e. 2.758 = 2.75 or 2.7, not 2.8

1. Live Events: Calculate the number of contact hours based on the components of the activity: post-tests, presentation, and clinical experience. Contact hours are calculated based on the components of the activity that are eligible for awarding CE credit. a. Welcome, introductions, pretest and breaks are not eligible for contact hours. b. Evaluation time may be included in the contact hours.

Show evidence (math calculation) of how contact hours were determined: Click here to enter text

2. Enduring materials (print, CD, web-based, etc.):

What was the method for calculating the contact hours? (Select one)☐ Pilot Study☐ Historical Data☐ Complexity of content and data☐ Other – Describe: Click here to enter text

Show evidence (math calculation) of how contact hours were determined: Click here to enter text

Disclosures Provided to Participants: Learners must receive disclosure of required items prior to the START of an educational activity.

☐ In live activities, disclosures must be made to the learner prior to initiation of the educational content.☐ In enduring materials (print, electronic, or Web-based activities), disclosures must be visible to the learner prior to

the start of the educational content.

Required disclosures may not occur or be located at the end of an educational activity. If a disclosure is provided verbally, an audience member must sign a document developed by the applicant with both the type of disclosure and the inclusion of all required disclosure elements.

Indicate how participants will be informed of each of the following required disclosures:Disclosure Applicable Where is this item disclosed

No YesPromotional/AdvertisingMaterials

Handout /

Packet

On screen/Disclosure

Slide

Sign in at Check-In

Area

Other * (Specify)

Activity Approval StatementSuccessful Completion Requirements



Presence/Absence of COI for Planners/Presenters/Authors/Content ReviewersCommercial Support (if applicable)Joint Providers Identified (if applicable)Expiration Date for Awarding Contact Hours (enduring material activities only)

* Applicants must specify method and provide written documentation.

☐ Copy of Disclosure Mechanism is attached (Attachment Eight)

Agenda & Promotional Materials:

Agenda:Submit an agenda clearly stating the time spent on learning activity, time spent on welcome, introductions, pre/post-tests, presentation, clinical experience, breaks, and evaluation.

☐ Copy of Agenda is attached (Attachment Five)

Promotional Materials: Indicate the method that will be used to promote the activity to the target audience:

☐ Flyer/brochure☐ Memo/letter☐ Meeting notice☐ Email ☐ Website/intranet ☐ Social media☐ Other – Describe: Click here to enter text

☐ Copy of Advertising Materials is attached (Attachment Six)

When referring to contact hours: The term "accredited contact hours" or “CEU” should never be used. An organization is accredited or approved; contact hours are awarded.

Approval Statement:The official ANCC approval statement must be provided to learners prior to the start of every educational activity and on each certificate of completion.

The approval statement must be: Displayed clearly to the learner Be written exactly as indicated by the Accredited Approver.

If advertising is released prior to approval AND after an application has been submitted, the following statements may be used:

This activity has been submitted to Louisiana State Nurses Association for approval to award contact hours. Louisiana State Nurses Association is accredited as an approver of continuing nursing education by the American Nurses

Credentialing Center’s Commission on Accreditation.

For more information regarding contact hours, please call (Applicant's contact person's name and phone number).

If the advertising is to be released after approval is received, then use the following statement:

This continuing nursing education activity was approved by the Louisiana State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Documentation of Completion:Participants receive written verification of successful completion of the activity, which must include:

Participant name Title and date of the activity



Name and address of the provider (Web address acceptable) Number of contact hours Official approval statement

This continuing nursing education activity was approved by the Louisiana State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

☐ Copy of completed Certificate to be awarded to participant is attached (Attachment Nine)

Qualified Planners and Faculty/Presenters/Authors/Content Reviewers: Complete the table below for each person on the planning committee; include name, credentials, educational degree(s), role on the planning committee, and expertise that substantiates their role. Planning committees must have a minimum of a Nurse Planner and one other planner to plan each educational activity. The Nurse Planner is required to have a bachelorette degree or higher, to be knowledgeable of the CNE process, and is responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered.

The Nurse Planner and Content Expert must be identified.A. Planning Committee:

Committee Member Name

Credentials & Degrees

Role on Committee

COIYes or No

Resolution Method Used(see list below)

Resolution Methods: (insert # of applicable methods above in table)1. Not applicable since no conflict of interest.2. Revised role of the individual with conflict of interest so the relationship is no longer relevant to the educational

activity.3. Not awarding contact hours for a portion or all of the educational activity. 4. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in

presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation.

5. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.

☐ Biographical Data/COI Forms (Attachment Four) are to be submitted to the Nurse Planner & Content ExpertIndividual responsible for reviewing conflict of interest information for Nurse Planner (Nurse Planner may not evaluate his/her own conflict of interest information): Click here to enter text.

B. Faculty/Presenters/Authors (FPA): FPA’s must have documented qualifications that demonstrate their education and/or experience in the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. The qualifications must address how the individual is knowledgeable about the topic and how expertise has been gained. FPA’s do not have to be nurses, but nurses should address nursing care and nursing implications, as applicable. Bio/COI Forms do not need to be submitted, however, a reviewer may request the Bio/COI form if there is a question about the individual.

Faculty/Presenter/Author Name Credentials / DegreesConflict of

InterestYes or No

Resolution Method Used(see list below)

(Tab to add more speakers)Resolution Methods (insert # of applicable methods above in table):1. Not applicable since no conflict of interest.2. Revised role of the individual with conflict of interest so the relationship is no longer relevant to the educational

activity.3. Not awarding contact hours for a portion or all of the educational activity.



4. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content, or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation.

5. Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content, or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.

1. Describe how the needed qualifications of FPA’s are identified (check all that apply):

☐ Content expertise☐ Demonstrated comfort with teaching methodology (i.e., web-based, etc.)☐ Presentation skills☐ Familiarity with target audience☐ Other – Describe: Click here to enter text.

2. Planning committee assures the qualifications of the FPA’s are appropriate & adequate by (check all that apply):☐ Review of resume/CV of FPA.☐ Recommendation by colleagues.☐ Review of literature written by FPA.☐ Observation of previous presentation by FPA.☐ New FPA’s being mentored by: Click here to enter text.☐ Other – Describe: Click here to enter text.

3. The following precautions have been taken to prevent bias in the educational content (check all that apply): See the ANCC’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities for examples of other methods to maintain content integrity.☐ Each FPA has agreed that s/he will present information fairly & without bias☐ The potential for bias was discussed with each presenter (trade names, relationships with commercial entities

& any commercial support received, etc.).☐ In conjunction with the above, the session will be monitored for potential violation(s) & any violations will be

addressed☐ Other – Describe: Click here to enter text.

Commercial Support and Sponsorship:A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, or distributing health care goods / services consumed by, or used on, patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes health care goods / services consumed by, or used on, patients.

Exceptions are made for non-profit or government organizations and non-health care related companies.

Commercial Support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity.

A Sponsor is identified as an organization that does not meet the definition of commercial interest. Sponsorship is financial, or in-kind, contributions given by an entity that is not a commercial interest, which is used to pay all or part of the costs of a CNE activity.

Will there be exhibitors and/or vendors at the educational activity?☐ No There will be no exhibitors and/or vendors at the activity. ☐ Yes The activity will have exhibitors and/or vendors.

Identify strategies/precautions that have been/will be taken to prevent bias/ensure content integrity with the presence of exhibitors/vendors. See the ANCC’s Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities for examples of other methods to maintain content integrity.NOTE: Exhibitor/Vendor display fees are not considered commercial support; however, precautions must be taken to ensure content integrity.☐ Exhibiting, promoting or selling products will not take place during scheduled educational time☐ Exhibit area will be physically separated from area where educational content will be delivered☐ Marketing/advertising will not be included within educational content (slides, handouts, etc.) or in participant

binders. A list of exhibitors is exempt but no logos can be visible on any participant’s handouts (including separation by tabs, etc.)

☐ ‘Giveaways’ will be kept separate from educational materials/delivery


http://arlascap.org/CE_course/RESOURCES/Content%20Integrity%20Standards%20for%20Industry%20Support.pdf





☐ Learner contact information will not be shared without written permission from the learner☐ Commercial interest organizations will not be allowed to influence the audience during the educational activity

for any reason

If no commercial support or sponsorship received, select A and go to Joint Providership.

If commercial support is received, complete items B, C, and D and attach the signed and dated agreement(s):

☐ Commercial Support Template Agreement (Attachment Seven)

A. ☐ This activity has no commercial support or sponsorship.

B. Commercial support/sponsorship has been provided by the following (list all individuals providing support):

Name of Organization DonationFunding or In-Kind

Type of Organization(commercial interest or sponsor)

C. Content integrity has been/will be maintained by (check all that apply):☐ Commercial support/sponsorship did not participate in the planning of the activity in any way. ☐ The commercial support/sponsorship policy/procedure has been discussed with those providing commercial

support or sponsorship.☐ The commercial support/sponsorship policy/procedure has been shared in writing with those providing

commercial support/sponsorship.☐ Support agreement terms and conditions will be discussed and clarified prior to signing☐ Faculty/Presenters/Authors have been informed of the policy/procedure re: commercial support and

sponsorship and agree to not promote the products or entity providing the financial or in-kind services.☐ Presence of commercial support and need to avoid bias will be discussed with each presenter/faculty/author. ☐ Advertising/company logos will be removed from any educational content (slides/handouts)☐ Educational materials will not be packaged in items bearing logos of a commercial interest. ☐ Commercial companies or supporters will not be referenced during the activity except for required

disclosures. In conjunction with above, the session will be monitored and violators of policy will not be asked to present again.

☐ Other – Describe: Click here to enter text.

D. All individuals listed in the table above must complete the Commercial Support Agreement and all agreements are to be submitted with the application. Signed commercial support or sponsor agreement, attached and includes:

Statement that the provider of commercial support or sponsorship may not participate in any component of the planning process of an educational activity, including:

o Assessment of learning needso Determination of objectiveso Selection or development of contento Selection of presenters or facultyo Selection of teaching/learning strategieso Evaluation

Statement of understanding that the commercial support or sponsorship will be disclosed to the participants of the educational activity

Statement of understanding that the provider of commercial support or sponsorship must agree to abide by the provider’s policies/procedures

Amount of commercial support or sponsorship and description of in-kind donation Name and signature of the individual who is legally authorized to enter into contracts on behalf of the provider

of commercial support or sponsorship Name and signature of the individual who is legally authorized to enter into contracts on behalf of the provider

of the educational activity Date the agreement was signed

☐ Other – Describe: Click here to enter text.

Joint Providership:This activity will:



A. ☐ NOT be Joint Provided. B. ☐ be Joint Provided.

1. Joint Providership of this activity has been arranged with: List organization(s) name(s): 1. Click here to enter text.2. Click here to enter text.

2. When an educational activity is joint provided, the Individual Activity Applicant's Nurse Planner is responsible for ensuring adherence to the ANCC Accreditation criteria and is responsible for the lowing items:☐ Determination of educational objectives and content ☐ Selecting planners, presenters, faculty, authors, and/or content reviewers☐ Developing evaluation methods☐ Awarding of contact hours☐ Recordkeeping procedures☐ Management of commercial support or sponsorship☐ Applicant organization (i.e. Provider Unit name is displayed on all marketing materials and certificates.)

Recordkeeping:Activity file records must be maintained in a secure, confidential, and retrievable manner (electronic or hard copy) for a minimum of 6 years. A participant must be able to contact the applicant organization if verification of attendance or a replacement certificate of completion is needed. The Nurse Planner is responsible for assuring that an adequate recordkeeping is in place.

Recordkeeping requirements for each activity file: Title and location (if live) of activity Type of activity format: live or enduring Date live activity presented or, for ongoing enduring activities, date first offered and subsequent review dates Description of professional practice gap Evidence that validates professional practice gap Educational need that underlies the professional practice gap Description of the target audience Desired learning outcomes Description of evidence based conn with supporting reference or resources Learner engagement strategies used Criteria for awarding of contact hours Description of evaluation method (Evidence that change in knowledge, skills, &/or practices of target

audiences was assessed) Names and credentials of all individuals in a position to control content (must identify who fills the roles of

Nurse Planner and content experts). Qualifications documentation for the Nurse Planner and the content expert Conflict of interest disclosure documentation from all individuals in a position to control content (planners/

presenters, faculty, authors, &/or content reviewers)o Name of individualo Past 12 monthso Spouse/significant othero Individual providing the information is provided a definition of a commercial interest organization

Evidence of a resolution of process, if applicable Number of contact hours awarded for activity & method of calculation (Note: Provider must keep a record of

the number of contact hours earned by each participant. If the activity is longer than 3 hours, agenda was provided for the entire activity.)

Documentation of completion &/or certificate must include:o Title and date of the educational activityo Name and address of provider of the educational activity (web address acceptable)o Number of contact hours awardedo Approver statement



o Participant name Commercial Support Agreement with signature and date (if applicable)

o Name of the Commercial Interest Organization (CIO)o Name of the Providero Complete description of all the CS provided, including both financial and in-kind supporto Statement that the CIO will not participate in planning, developing, implementing or evaluating the

educational activityo Statement that the CIO will not recruit learners from the education activity for any purposeo Description of how the CS must be used by the Provider (unrestricted use &/or restricted use)o Signature of a duly authorized representative of the CIO with the authority to enter the binding contracts

on behalf of the CIOo Signature of a duly authorized representative of the Provider with the authority to enter the binding

contracts on behalf of the Providero Date on which the written agreement was signed

Evidence of disclosing to the learner:o Approval statement of provider awarding contact hourso Criteria for awarding contact hourso Presence or absence of conflicts of interest for all individuals in a position to control content (planning

committee, presenters, faculty, authors, &/or content reviewers)o Commercial support (if applicable)o Expiration date (enduring material only)o Joint Providership (if applicable)o Materials associated with this activity (marketing materials, advertising agendas, and certificates of

completion) must clearly indicate the Provider awarding contact hours and responsible for adherence to the ANCC criteria

Summative evaluation Sign in Sheets

A. The Nurse Planner and applicant organization agree to maintain all required records (listed above) in a secure, confidential, and easily retrievable manner (electronic or hard copy), accessible to authorized personnel only, for a minimum of six years. ☐Yes

B. How do you ensure all required records are collected?☐ Checklist used to verify (including required records above)☐ Consistent (same) individual responsible for collection☐ Other – Describe: Click here to enter text.

C. Where will records be stored?☐ Office of Nurse Planner☐ Office of Contact Person for this application ☐ Applicant Organization office☐ Other Location (Name & Address): Click here to enter text.

D. Provide contact information for individual responsible for reporting to the LSNA CNE coordinator with post activity documentation and/or response to the audit (Annual Report) request.

Name: Click here to enter text.Email: Click here to enter text.Phone: Click here to enter text.

E. In what format will records be stored?☐ All hardcopy files☐ All electronic files *please ensure properly backed-up☐ Combination of hardcopy and electronic

F. How are files containing confidential or sensitive information about planners, presenters/faculty/authors, and content reviewers, and/or participants secured?

☐ Hardcopy files will be in locked file and/or office will be locked☐ Electronic files will be on password protected computer or limited access storage on server



☐ Participant records maintained on Learning Management System (LMS) will have limited access☐ Other System – Describe: Click here to enter text.

Who will have access to the secure/confidential files?☐ CNE Nurse Planner☐ Contact person for application☐ Other - List Names: Click here to enter text.
