MONTANA NURSES’ ASSOCIATION CONTINUING NURSING EDUCATION APPLICATION INSTRUCTIONS FEES -- Fees for approval of continuing nursing education activities are valid January 1, 2008 through December 31, 2008. The fee for approval of one application is $100.00 or the cost of one full registration, whichever is greater. Fee includes consultation with Continuing Education Director as needed. Applications are processed only upon receipt of fee payment. DUE DATES -- Applications are accepted by hard copy, fax, or email. See the Application Checklist for items that must be included. The application must be complete in order to be considered “accepted”. If the application is not complete, the sender will be notified with notations of missing information. Do not include copies of handouts or curriculum vitae. MNA-approved forms must be used to complete all C.E. requirements. Complete applications must be received in the MNA office no later than 45 days prior to the date of the planned activity if submitting in hard copy. Thirty (30) days are required if submitting by email. Applications received after the deadline require a 50% late fee (an additional amount of 50% of the application fee) and processing is not guaranteed prior to the start of the activity. Approval must be sought and granted prior to implementation of the educational activity. The American Nurses Credentialing Center Commission on Accreditation (ANCC) does not permit awarding of contact hours retrospectively. Thirty (30) days after the activity is concluded, the provider must submit 1) a copy of the attendance roster and 2) an evaluation summary to the MNA CE Director. This can be done electronically or in hard copy/fax. Do not submit the evaluation forms – only submit a summary of those evaluations. Failure to provide the post-activity paperwork by the due date may prohibit approval of any future CE requests. If you need to request an extension, please contact the MNA CE Director. ADVERTISING APPROVAL -- The applicant may indicate that approval is being sought from MNA in promotional materials for the continuing education activity not yet approved. However, publicity that implies or states that MNA approval has been granted may not be mailed / published until approval is received, in writing (email/fax) or by telephone from MNA headquarters. You are invited to advertise your educational activity in the MNA newsletter, The Pulse, and on the MNA website at no cost.
______ Please advertise my educational activity in The Pulse and/or on the MNA website.
LENGTH OF APPROVAL -- Applicants are authorized to use the MNA-issued ID# and contact hours authorized during a 24 month period for which the CE activity is approved. If the SAME activity is presented again within that 24 month period, the same ID# and contact hour assignment is authorized without reapplication, provided there are not appreciable changes. If different presenters are used, the biographical data form with vested interest statement must be submitted as an addendum to the original application, as long as that faculty member is equally qualified and uses the same objectives and content outline. No fee is charged for such addendums. CONFIDENTIALITY -- All information relative to applications/applicants will be kept strictly confidential.
| MNA CE APPLICATION CHECKLIST MUST BE COMPLETED AND SIGNEDBEFORE SUBMISSION |
Office Use Only |
Date Received |
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| Fee Submitted |
$ |
| Late Fee, if Applicable |
$ |
| CE # Assigned |
MNA # |
____ REVIEW FEE (fee will need to be sent separately WITH A COPY OF THIS CHECKLIST if submitting complete application electronically). Applications are not processed until the review fee is received in the MNA office. ____ LATE FEE if submitting complete application in hard copy less than 45 days before the activity start date & if submitting application electronically, less than 30 days before the activity start date. ____ HARD COPY APPLICATION -- Original and 1 copy of the completed application, limited to: ___ application form WITH complete agenda___ biographical data forms of all planners and presenters (in the order of presentation per the agenda)___ advertising materials or brochure___ certificate___ evaluation form___ commercial support agreement(s), if applicable___ co-provider agreement(s), if applicable ____ ELECTRONIC APPLICATION: The documents/attachments are limited to:___ application form WITH complete agenda ___ biographical data forms of all planners and presenters AS ONE DOCUMENT – do not submit separate Word documents for each planner and presenter – they MUST be in one document in the order of presentation per the agenda ___ advertising materials or brochure___ certificate___ evaluation forms___ commercial support agreement(s) if applicable___ co-provider agreement(s), if applicable I signify that the application being submitted is complete; all questions are answered accurately and completely. If the application is incomplete, I am aware that a late fee may be required prior to processing and approval of the application. I also agree to submit the attendance roster and evaluation summary within 30 days of the activity conclusion. ._______________________________________________________________________________ Printed or typed name of person completing the application Date __________________________________________________________________Signature__________________________________________________________________Name of facility / organization
MONTANA NURSES’ ASSOCIATION Faculty Directed Activity CE Application |
Directions: This form may be copied in its entirety. All information must be completed in this format to be considered for review. NOTE: This form is to be used only by applicants for MNA CE contact hours. Adapted from the Ohio Nurses’ Association which is accredited by ANCC as an Approver of Continuing Nursing Education. |
Demographic Data Title of Activity _________________________________________________________________________ Date (s) of event ______________________________________ Contact hours requested* __________ If series of events or multiple locations, please explain ________________________________________
*NOTE -- 60 minutes of instruction equals one Contact Hour. The minimum number of Contact Hours that can be awarded is 0.5 contact hours.
Human Resources & Location of Provider 1. Contact Person -- Provide the following information for the contact person for this activity. If this person is also on the planning committee, be sure to include his/her name in the Planning Committee list. Name & Credentials _________________________________________________________________ Organization/Provider of the Activity ____________________________________________________ Daytime Phone # including extension (______) __________________Fax Number________________ Email Address (important!) ____________________________________________________________ Business Address ___________________________________________________________________ Street/PO Box City State Zip 2. Planning Committee -- MUST include a designated Registered Nurse Planner and at least one other committee member. For each person listed, please include name, credentials and all area(s) a committee member represents. Include a biographical data form with the additional required information including conflict of interest/vested interest declaration. To meet the “ANCC Criteria” requirement the planning committee member must ensure the objectives are measurable, the content flows from the objectives, evaluation includes both objectives & presenters, the presentation is free from bias and/or conflict of interest is disclosed and that all disclosures are made.
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NAME |
CREDENTIALS |
Represents |
| ANCC Criteria |
Content Expert |
Target Audience |
| Designated Nurse Planner |
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| Other Planning Committee Members |
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_____ Biographical Data Form with conflict of interest/vested interest declaration for each PLANNER is included. Physical Facilities for the Event (provide the Facility Name & Address) _______________________________________________________________________ Street City State Zip Target Audience (must include RNs)
| _X_ RN |
___ Advanced Practice Registered Nurse |
___ LPN |
___ RPh |
| ___ MD/DO |
___ RT |
___ PT |
___ OT |
| ___ Social Workers |
___ EMT / Paramedic |
___ MT Certified Med. Aides |
___ Other, Describe |
Needs Assessment Used (Check All That Apply)
| ___Written Needs Assessment/Survey ___Learners/Management Requested Event ___ Other, Describe |
___Trends in Literature, Law & Health Care ___Quality Studies / Performance Improvement Offerings |
Purpose/Goal Statement for this Activity: __________________________________________________ Objectives, Content & Teaching Methods Use the 5-column format at the end of this document and duplicate that page as needed. Present the information in order of presentation per the agenda. ¨Faculty / Presenters – in addition to listing names on the program agenda & in the content area, attach the completed biographical data form for each presenter.
___ Biographical Data Form with conflict of interest/vested interest declaration for each PRESENTER is included.
¨Objectives -- Indicate what the learner will be able to do at the conclusion of the activity. An average of 1-2 objectives per hour is realistic. Indicate applicability to each member of the target audience if the objective deals with hands-on clinical practice (i.e. demonstrate, etc.). Please number the objectives consecutively. ¨Content Outline -- Include an outline of the content for each objective. It must be more than a restatement of the objective and must flow from the objective. ¨List number of minutes for each TOPIC plus EVALUATION TIME. ¨Teaching-Learning Strategies -- List the methods, strategies, materials and resources to be used by faculty to cover each CONTENT AREA. The strategies should be congruent with the stated objectives.
___ This activity meets the definition of continuing education. It is not in-service, orientation, basic nursing education or personal development.
Co-providership -- If not co-providing, check #1. 1. ___ This activity will not be co-provided. If yes, complete #2. 2. ___ Co-providership of this activity has been arranged with (List organization name)
| Organization Name |
| Address |
| Street City State Zip |
____ A co-providership agreement is enclosed (required for each organization involved – see sample on website.
Commercial Support -- If no, check #1. 1. ___ This activity has no commercial support. If yes, complete items 2, 3, 4, and 5. 2. Commercial support has been provided by the following: (List names of companies/organizations providing commercial support for specific presenters and educational sessions. This does not include those paying for display booths in a separate vendor area)
3. Content integrity will be maintained by (Check all that apply)_____ a. Our commercial support policy/procedure has been discussed with those providing commercial support._____ b. Our commercial support policy/procedure has been shared in writing with those providing commercial support._____ c. Faculty has been informed of our policy/procedure re: commercial support._____ d. The Nurse Planner / designee will monitor session. Violators of policy will not be asked to present again._____ e. Other, Describe 4. The following precautions will be taken to prevent bias in the educational content. _____ a. Our position on commercial support and bias has been discussed with each presenter. _____ b. Each presenter has signed a statement that says s/he will present information fairly and without bias. _____ c. The Nurse Planner or designee will monitor session and violators of policy will not be asked to present again. _____ d. Other, Describe 5. ____ Signed agreement re: commercial support is attached for each organization providing commercial support. Evaluation 1. Check or describe the methods of evaluation to be used (Check all that apply)___ Evaluation Form including each objective and each presenter (Required)___ Pre and/or Post-test (Optional)___ Return Demonstration (Optional)___ Other, Describe 2. Attach a copy of the evaluation tool(s) to be used for this activity. It must include, at a minimum, achievement of each objective and teaching effectiveness of each presenter. ___ Evaluation form(s) is (are) included/attached. 3. The type of evaluation to be used for this activity: (Check all that apply)
| ___ Change in practice/performance___ Relationship of the practice change to quality of service |
___ Learner satisfaction___ Knowledge enhancement___ Skill and attitude change |
4. Check the best description or describe how evaluation data will be used___ Refine future presentations of this course.___ Create new programs.___ Discontinue the activity.___ Decide whether or not to change this faculty or facility.___ Other, Describe 5. Learner Feedback: Check the best description or describe how learners will be provided feedback.___ Question and answers during activity.___ Return results of testing.___ Provide certificate.___ Follow-up communication.___ Other, Describe 6. Quality Improvement: Describe how the Nurse Planner will review the activity for continued relevance, need for content updates or changes, etc. (Check all that apply)___ Review of each presentation of an activity___ Review prior to presenting activity if it is more than one year old___ Annual review___ Feedback from faculty and/or learners___ Documentation of the review and changes/recommendations will be done via minutes or standardized form.___ Other, Describe Attendance/Participation 1. ___ Attendance/participation will be verified at the event through sign in sheets or attendance sheets (required) and, if applicable ___ Other, Describe 2. Criteria for successful completion include (Check all that apply)___ Attendance at entire event.___ Attendance at least 80% of event.___ Completion/submission of evaluation form.___ Achieving passing score on post-test.___ Other, Describe 3. Documentation of completion: Attach a copy of the completed certificate to be awarded to participants who meet the completion requirements. The certificate must include the provider’s complete address and the following statement exactly as stated below:
“This activity has been approved by the Montana Nurses’ Association, which is accredited as an approver of continuing nursing education by the American Nurses’ Credentialing Center (ANCC) Commission on Accreditation.” Expiration February 2009
Agenda / Schedule -- The agenda for the entire activity must be attached. If the activity is less than two hours, the time frames need to be included only on the objectives/content outline forms. Clearly delineate time spent on welcome, introductions, pre/post tests, breaks and evaluation. The time frames on the schedule and the objective/content outline pages must match and must support the number of contact hours requested. Advertising Material -- Include a copy of the advertising material including relevant pages of the web site (if applicable). Check the types of advertising used (Check all that applies.)
| ___ Flyer/brochure___ Memo/Letter |
___ Meeting Notice___ E-mail |
___ Web site___ Other Describe |
___ If a mock-up is included with the documentation form, the final copy must be included in the file as soon as it is completed. ___ If advertising is via the web site, include the address so that reviewers can find this information. Include the URL (web site address) for the provider statement and advertising material. The URL is _______________________________________________________________Record Keeping ___ All correspondence, complete copy of documentation form and all attachments and corrections, records of attendance, summative evaluation(s) and contact hours will be maintained in a retrievable file which is accessible to only authorized personnel for six years as defined by policy. Disclosures – The following disclosures must be documented.
| Criteria For Successful Completion |
1. Learners will be informed of criteria for successful completion by___ Information on advertising material. ___ Verbal statement at beginning of activity.___ Written information on handouts.___ Other, Describe |
| Conflicts Of Interest – Or Lack Thereof - |
2. Learners will be informed of conflicts of interest or lack thereof for planners and presenters by: (“Not Applicable” is not an acceptable response -- MUST CHECK AT LEAST ONE)___ Announcement at beginning of session. The above option must be documented in writing that it occurred by a representative of the activity provider who attended the event. Name of the person who will do this _______________________________________ Information provided on advertising.___ Information provided on handouts.___ Signs placed inside or outside of presentation room.___ Other, Describe |
| Commercial Support - Or Lack Thereof - |
3. Learners are informed of commercial support OR lack thereof by (CHECK AT LEAST ONE)___ No commercial support being received for this event. (No statement needs to be made.)___ Announcement at beginning of session. The above option must be documented in writing that it occurred by a representative of the activity provider who attended the event. Name of the person who will do this _______________________________________ Information provided on advertising.___ Information provided in handouts.___ Signs placed inside or outside of presentation room.___ Other, Describe |
| Non-Endorsement of Products (if commercial support received) |
4. Learners are informed of non-endorsement of products if commercial support received.___ No commercial support being received for this event. (No statement needs to be made.)___ Information provided on advertising.___ Information provided in handouts.___ Verbal statement made at the beginning of the session.___ Other, Describe |
| Discussion of Off-Label Use |
5. Learners are informed of discussion of off-label use by faculty by___ Faculty have attested that they will not be discussed off-label usage of products. (No statement needs to be made.)___ Faculty will state at the beginning of their session discussion of off-label use of products.___ Information will be provided in the handouts.___ Other, Describe |
| Educational Merit / Non-endorsement of complementary / alternative / therapeutic modalities. |
6. Learners are informed of assessment of educational merit / non-endorsement of complementary / alternative/therapeutic modalities by the following___ Not applicable since not being discussed.___ Information provided verbally at the start of the activity.___ Information provided on handouts.___ Information provided on advertising.___ Other, Describe |
Objectives, Content & Teaching Methods – Duplicate as needed. Two – three objectives per session (1-2 objectives per hour) should be sufficient.
| OBJECTIVES |
CONTENT (Topics) |
TIME FRAME |
PRESENTER |
TEACHING METHODS |
| List learner’s objectives in behavioral terms. Refer to Bloom’s Taxonomy for help. Participants will be able to: |
Provide an OUTLINE of the content for each objective; it must be more than a restatement of the objective. |
State the number of minutes to be used for each objective. |
List the faculty for each objective or session. |
Describe the methods to be used for teaching by checking all that apply. |
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___ Lecture___ Power Point___ Discussion Q&A___ Small groups___ Slides/Video/DVD___ Transparencies___ Other |
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___ Lecture___ Power Point___ Discussion Q&A___ Small groups___ Slides/Video/DVD___ Transparencies___ Other |
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___ Lecture___ Power Point___ Discussion Q&A___ Small groups___ Slides/Video/DVD___ Transparencies___ Other |
| Objective # |
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___ Lecture___ Power Point___ Discussion Q&A___ Small groups___ Slides/Video/DVD___ Transparencies___ Other |
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