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NORTHEAST MULTISTATE DIVISION INDIVIDUAL EDUCATIONAL ACTIVITY APPLICATION -2015 Criteria

Always download a new application from the website to ensure you have current version and requirements.Do no use saved file copies of this application as items may change to maintain ANCC compliance.

Directions: Only typed, electronic applications will be accepted. Please complete all questions on the application and include all required attachments. Attachments should be labeled and numbered in accordance with the application. Application must be submitted as one (1) collated Word or Adobe. Pdf file to [email protected] Questions: contact the Northeast MSD Professional Development Associate at [email protected] or call 1.888.373.1291, Ext 2

DEMOGRAPHIC DATAApplicant/Organization Name:

Applicant/Organization Address:

Nurse Planner Name and Credentials: License No: State(s) in which licensed as a RN:

Nurse Planner Email Address: Nurse Planner phone number:

Secondary Contact Person: Title/Position:

Secondary Contact Email Address: Secondary Contact phone number:

A currently licensed registered nurse with 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, as well as the application process. The Nurse Planner (listed above) must be available to Northeast MSD Nurse Peer Reviewers to answer questions pertaining to the activity and information provided in this application.

☐Yes ☐No If no, the activity is not eligible to continue the application process

The Nurse Planner must be a registered nurse who holds a current, unencumbered nursing license (or international equivalent) AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education activity.

ELIGIBILITY VERIFICATION1. Does the individual serving as Nurse Planner meet all of the following requirements?

Is currently licensed as a registered nurse Is NOT an employee or representative of a commercial interest Has NO relevant relationship with a commercial interest(COI) with respect to the content of the activity Is in compliance with all applicable federal, state and local laws and regulations that affect the

organization’s ability to meet the ANCC/Northeast MSD accreditation criteria☐Yes, Nurse Planner meets all above requirements. Proceed to #2☐No (If no, the applicant is not eligible to continue)

2. Is Your Organization A ‘Commercial Interest’?A ‘commercial interest’, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. Nonprofit or government organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests.

Does your organization produce, market, re-sell, or distribute health care products or services consumed by, or used on patients?

☐NO, your organization is eligible to apply for approval; continue to Statement of Understanding☐YES, However, my organization is one of the exempt organizations below-please check one

Identify Applicant’s Organization Type-please select one:☐ Constituent Member Association of ANA or Specialty Nursing Organization☐ College or University☐ Hospital, nursing home or rehabilitation center; for-profit or nonprofit☐ Nonprofit organization or professional association

Northeast Multistate Division Individual Activity Application v2.2018 New 2015 ANCC Criteria 1

mailto:[email protected]


☐ Government organization☐ Blood bank☐ Diagnostic laboratory☐ Federal Nursing Service☐ Group medical practice☐ Health insurance providers☐ Liability insurance providers☐ Non-healthcare related company☐ Provider of clinical services or clinical education☐ National nurse’s organizations based outside the United States☐ Healthcare information Technology Company☐ A single-focused organization *devoted only to providing continuing nursing education

Note: 501c applications are not automatically exempt. The ANCC Accreditation Program requires 501c applicants to be screened for eligibility.

*If you checked ‘YES’ and your organization is not one of the types above, proceed to # 3 to determine your eligibility to apply.

3. Your organization indicated it meets the definition of commercial interest and is not an exempt organization form the list above. The following questions must be answered to assess the organization’s eligibility to offer continuing nursing education.

4. Does the applicant produce, market, re-sell, or distribute health care goods or services consumed by, or used on patients and not an exempt organization?

☐ NO, continue to next questions☐ YES, STOP your organization is not eligible to apply

5. Is this applicant organization owned or controlled by a multi-focused (MFO) organization that is a commercial interest organization by ANCC definition and produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients?

☐ NO, this section of the eligibility is complete. Continue to Statement of Understanding.☐ YES, continue to next question

6. Is the application a separate and distinct entity from the MFO?☐ NO, STOP your organization is not a separate and distinct entity from the MFO; therefore, you are not eligible

to apply for nursing contact hours approval.☐ YES, continue to Statement of Understanding

STATEMENT OF UNDERSTANDING BY AUTHORIZED REPRESENTATIVE

On behalf of [Insert Name of Applicant Organization], I hereby attest that the information provided in this application is true, complete, and correct. I further attest, by my signature below that they will comply with all eligibility requirements and approval criteria throughout the approval period, and will notify the Northeast Multi-State Division promptly, if, for any reason while this application is pending or during any approval period it does not maintain compliance.

I understand that any misstatement of material fact submitted on, with or in furtherance of this application for activity approval shall be sufficient cause to the Northeast Multistate Division to deny, suspend or terminate approval of this activity and to take other appropriate action against [Insert Name of Applicant Organization].

☐ Electronic Signature (Required) Date: Click here to enter a date.

Name and Credentials of duly authorized representative of the Provider


ACTIVITY INFORMATION

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.

ACTIVITY TITLE:

Enter below the number of contact hours offered and the total under review for this activity. For example, an activity that is 60 minutes in length, with three concurrent presentations is 3.0 contact hours to be reviewed and 1.0 contact hour offered that a participant can receive.

Number of participant contact hours offered: Number of contact hours to be reviewed:

ACTIVITY TYPE: ☐ Provider-directed, provider-paced: Live (in person or webinar) Date of live activity: Select Date Location of Activity Method of Calculation

☐ Provider-directed, learner-paced: Enduring material Start date of enduring material: Select Date Expiration/end date of enduring material: Select Date Method of Calculation

☐ Blended activity Date of live portion of activity: Select Date Date(s) of enduring materials (e.g. pre-work, post live etc.):

o Start date of enduring material: Start Dateo Expiration/end date of enduring material: End Dateo Method of Calculation

COMMERCIAL SUPPORT AMOUNT (IF APPLICABLE):

Total Amount of Commercial Support Please (see Attachment 4) and include all agreement.

JOINTLY PROVIDED (IF APPLICABLE)☐No ☐Yes Insert organization(s) name(s) Please (see Attachment 7) and include all agreements.

EDUCATION NEEDS IDENTIFICATION AND ASSESSMENT OF LEARNER NEEDS

A. Description of the professional practice gap: (e.g. change in practice, problem in practice, opportunity for improvement)Describe the Current State (Currently happening)

Describe the Desired State: (Should be happening)

Identified Gap: (Difference between the Current & Desired States)


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/or health care☐ Trends in practice, treatment modalities and/or technology☐ Direct observation☐ Other—Describe:

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/or practices)☐Gap in knowledge (does not knows)☐Gap in skills (does not know how)☐Gap in practice (does not shows/do in practices)☐Other- Describe:

EDUCATION DESIGN PROCESS

D. Description of the target audience. (You can select more than one target audience).☐ RNs☐ Advanced Practice RNs☐ RNs in Specialty Areas (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?)

Area of impact (check all that apply):☐ Nursing Professional Development ☐ Patient Outcome ☐Other- Describe:

F. Outcome Measure(s) : (A quantitative statement as to how the outcome will be measured to assess the impact of this educational activity in closing the identified gap):

G. Content of activity : A description of the content with supporting references or resources.All references and resource need to be listed on the bottom of the Northeast MSD planning table. (attachment 1)

☐ Described on Educational Planning Table (See Attachment 1)

Content for this educational activity was chosen from:☐ Information available from the following organization/web site (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, National Institutes of Health):

☐ Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years):

☐Clinical guidelines (example - www.guidelines.gov) List here:

☐ Expert resource (individual, organization, educational institution) (book, article, web site) List here:

Presenter references: When the presenter(s) are the expert resource and source of the content’s supporting references and resources the nurse planner informs them of the ANCC requirement to create their content from the best available current evidence or evidence-based references and obtains a list of at minimum the top 1-2 references:

☐Textbook reference

☐Other:

H. Individuals in a Position to Control Content

Complete the table below listing each person in a position to control content of the educational activity. Include name, credentials, educational degrees(s), role in the activity, and any financial relationships with a commercial interest entity that is relevant to the content.

There must be at least two people --one Nurse Planner and one other planner to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria AND hold a baccalaureate degree or higher in nursing (or International equivalent) AND be activity involved in planning, implementing and evaluating this continuing education activity. One planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert) and can also be the Nurse Planner or a Presenter who is on the Planning Committee. The individuals who fill the roles of Nurse Planner and Content Expert must be identified.

Columns D and E relate to the nurse planner's assessment of Conflict of Interest for the individuals in column A."Conflict of Interest exists when an individual is in a position to control or influence the content of an education activity and has a financial relationship with a commercial interest organization the products or services of which are pertinent to the content of the educational activity."

For questions when assessing conflict of interest for columns D and E review the ANCC standards: http://www.nursecredentialing.org/Accreditation-CEContentIntegrity.pdf

A B C D EName of individual and credentials Role(s) in activity

Nurse Planner (only one)

Content Expert Other Planner Presenter/Author

Planning committee member? (Yes/No)

Commercial interest relationship relevant

to the content?(Yes/No)

If yes in D Name of Commercial

Interest and nature of relationship

Example: Jane Smith, BSN, RN Nurse Planner Yes No n/a

Example: Sue Brown, PhD, RN Content Expert Yes No n/a

Example: Ida Row, MSN, RN Other Planner Yes No n/a

Example: John Doe, MD Presenter No Yes Pfizer Speakers Bureau

Qualifications for the Nurse Planner: Provide information about expertise/education in adult education or adult learning and ANCC credentialing criteria.

Qualifications for the Planning Committee Content Expert(s): Describe professional experience or areas of expertise, which contribute to content expertise for this activity. May include educational background, professional/practice experience, and publications.


http://www.nursecredentialing.org/Accreditation-CEContentIntegrity.pdf

http://www.guidelines.gov/

I. Learner engagement strategies ☐See Educational Planning Table and/or check below which strategies will be used:☐ Integrating opportunities for dialogue or question/answer☐ Including time for self-check or reflection☐ Audience response system☐ Analyzing case studies☐ Providing opportunities for problem-based learning☐ Pre/Post Test☐ Other:

J. Contact Hour Calculation Contact hours are determined in a logical and defensible manner and awarded to participants for those portions of the educational activity devoted to learning and evaluation. One contact hour = 60 minutes. Fractions or portions of the 60-minute hour can be awarded. For example, 135 minutes equals 2.25 contact hours. Do not round up (e.g. 2.758 should be 2.75 or 2.7, not 2.8).

Time for registration, introductions, opening announcements, breaks, meals, business meetings and viewing of exhibits are excluded from the calculation of contact hours. Viewing of poster sessions and evaluations are included.

1. Attach educational planning table– from registration to closing. (Attachment 1)2. Enter the maximum number of contact hours a participant could earn for this activity: 3. Identify the method used to calculate the number of contact hours awarded to each participant:

☐ Total number of eligible minutes for each session attended divided by 60 ☐ Pilot study – average time for completion of activity by testers☐ Historical data – compared this activity to a similar existing enduring material activity☐ Professional opinion based on complexity of content and delivery method☐ Mergener Formula http://touchcalc.com/calculators/mergener used for text content

Number of Words Number of Questions Degree of Difficulty

☐ Other (Describe):

K. Criteria for Awarding Contact Hours Criteria for awarding contact hours for live and enduring material activities include: (Check all that apply)

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

☐ Credit awarded commensurate with participation☐ Attendance at 1 or more sessions ☐ Completion/submission of evaluation form ☐ Successful completion of a post-test (e.g., attendee must score % or higher)☐ Successful completion of a return demonstration ☐ Other - Describe:

L. Description of evaluation method: How will change in knowledge, skills, and/or practice be evaluated at the end of this activity? (Refer back to identified practice gap and education need – evaluation must occur at the level of need identified in section “C” above)

Short-term evaluation options:


http://touchcalc.com/calculators/mergener

☐ Participant evaluation with self-report Intent to change practice☐ Active participation in learning activity☐ Post-test☐ Return demonstration☐ Case study analysis☐ Role-play☐ Other – Describe:

Long-term evaluation options:☐ Self-reported change in practice☐ Change in quality outcome measure☐ Return on Investment (ROI)☐ Observation of performance☐ Other – Describe:

POST ACTIVITY DOCUMENTATION

M. Summative Evaluation :

Documentation after the event the summarizing the findings from the participant evaluations and determination by the nurse planner of need for any follow up action steps. Includes total number of participants and total contact hours earned by each participant.

N. NEMSD Post-Activity Documentation Form

Within 30 days after the completion of the first presentation of this education activity, the Nurse Planner must submit to [email protected] the Post-Activity documentation form which includes submitting the total number of participants and total commercial support funds received for reporting to ANCC.

O. Record Keeping Requirements

☐ By checking this box, the applicant acknowledges responsibility for maintaining documentation for each educational activity in a secure, confidential, and retrievable manner for six years from the last date the activity was provided. Learners 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 system is in place. The recordkeeping files must include all the ANCC required documentation. See Recordkeeping Checklist.


http://www.nemsd.org/Doc-Vault/Individual-Activity-Application-and-Forms/8-Post-Activity-Documentation.docx


ATTACHMENTS

Please provide evidence of the following by including these Attachments:

Attachment 1 Educational Activity Planning Table required for all activities. (If the activity is 3 or more hours, a full agenda timeline from registration to closing is also required)

Attachment 2 Conflict of Interest (COI) Forms required for all individuals in a position to control content (e.g. planners, presenters, faculty, authors, and/or content experts and reviewers)

Attachment 3 Documentation of completion and/or certificate.Number of contact hours awarded for activity, including method of calculation (Provider must keep a record of the number of contact hours earned by each participant.)

Attachment 4 Commercial Support Agreement with signature and date (if applicable)

Attachment 5 Disclosures/ Evidence of required information provided to learners prior to start of the activity:1. Approval statement as issued by the Northeast Multistate Division2. Learning Outcomes3. Criteria for successful completion in order to receive contact hours4. Declaration of presence or absence of conflicts of interest for all individuals in a

position to control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers) If COI is present, disclosure must include name of person, type of relationship, and name of commercial entity.

5. Commercial support (if applicable)6. Expiration date (enduring materials only)7. Name(s) of Joint Providership(s) (if applicable)

NOTE: Materials associated with the activity (marketing materials, advertising, agendas, and certificates of completion) must clearly indicate the Provider awarding contact hours and is responsible for adherence to ANCC criteria)

Attachment 6 Participant evaluation sample

Attachment 7 Joint Providership (If applicable)

Post-Activity Reminder

Summative evaluation-submission after the activity has been completed per the Northeast Multistate Division (See- section M and N) for requirements

Completed by:

Date: Click or tap to enter a date.


Attachment 1Attach Educational Activity Planning Table

[Provider’s Name]Educational Planning Table – Live/Enduring Material

Title of Activity:

Identified Gap(s):

Description of current state (reference Section A of application):

Description of desired/achievable state (reference Section A of application):

Gap to be address by this activity: ☐ Knowledge ☐ Skills ☐ Practice ☐ Other: Describe

Learning Outcome (s) for this activity as a result of participants taking part in the activity (reference Section E of application):

Select all that apply: ☐ Nursing Professional Development ☐ Patient Outcome ☐ Other: Describe CONTENT

Provide an outline of the content to be presented, related to each learning outcome, in sufficient detail to determine consistency with learning outcomes, selected learner engagement strategies and appropriate time allotted.

(Restatement of learning outcomes does not meet the criteria)

TIME FRAMEList the number of minutes for each topic/ content area and/ or active learner engagement strategies.

PRESENTER/ FACULTY/AUTHOR

List the presenter, faculty person or author for each content area.

LEARNER ENGAGEMENT STRATEGIESList the learner engagement strategies to be used by Faculty, Presenters, Authors (Example: Question/Answers, Audience response system, Role Play, small group discussion, analyzing case studies)

Information from organization/website:(current available evidence within past 5-7 years; may be published or unpublished content. Examples –Agency for Healthcare

CONTENTProvide an outline of the content to be presented, related to each learning outcome, in sufficient detail to determine consistency with learning outcomes, selected learner engagement strategies and appropriate time allotted.

(Restatement of learning outcomes does not meet the criteria)

TIME FRAMEList the number of minutes for each topic/ content area and/ or active learner engagement strategies.

PRESENTER/ FACULTY/AUTHOR

List the presenter, faculty person or author for each content area.

LEARNER ENGAGEMENT STRATEGIESList the learner engagement strategies to be used by Faculty, Presenters, Authors (Example: Question/Answers, Audience response system, Role Play, small group discussion, analyzing case studies)

Research and Quality, Centers for Disease Control, National Institutes of Health). Provide full web page citations for material referenced, not “CDC.org”.

Peer –reviewed journal/resource:(reference should be within past 5-7 years)

Clinical guidelines:(published or online. Example -www.guidelines.gov)

Expert resource:(individual, organization, or educational institution - book, article, website)

Textbook reference:

Other:

If Live:Note: Time spent evaluating the learning activity may be included in the total time when calculating contact hours.

Total Minutes divided by 60= contact hour(s)

If Enduring:Method of calculating contact hours: Number of Contact Hours to be awarded:

☐Pilot Study ☐Mergener formula ☐ Historical Data ☐Complexity of Content ☐Other: Describe

______________________________________________________________ ____________________________________Completed By: Name and Credentials Date

Attachment 2Conflict Interest Forms

(All names listed in section H require a COI forms)Available online

Conflict of Interest FormDIRECTIONS: Type information directly into the space provided or type an ‘X’ in the appropriate box to indicate your response. Save the completed form to your computer.

Section 1: Demographic DataName & Credentials:

Present Position:

(job title, employer, city, state)

Mailing Address:

Phone: Email:

NOTE: The Northeast MSD reserves the right to ask for information on how the presenter’s qualifications were validated.

Section 2: Educational Activity

Educational Activity Title:

Individual Session Title (if different):

Education Activity Date(s):

Individual’s role(s) in this Educational Activity: (Check all that apply)

☐ Nurse Planner ☐ Presenter/Faculty/Author ☐ Content Expert ☐ Content Reviewer ☐ Other:

Section 3: Actual, Potential & Perceived Conflict of InterestThe potential for Conflict of Interest (COI) exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest, the products or services of which are pertinent to the content of the educational activity. Actions must be taken to resolve any potential or actual COI for planners, presenters/faculty/authors or content reviewers prior to the start of the educational activity.

Each individual who is in a position to control or influence the content of an education activity must disclose all relevant relationships with any commercial interest, including but not limited to members of the planning committee, speakers, presenters, faculty, authors, and/or content reviewers.

Relevant Relationships, as defined by ANCC, are relationships that are expected to result in financial benefit from a commercial interest organization, the products or services of which are related to the content of the educational activity.

Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated and resolved. Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options), grants, contracts, or other financial benefit directly or indirectly from the commercial interest. Financial benefits may be associated with employment, management positions, stockholder, independent contractor relationships (including contracted research), other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership , and other activities from which remuneration is received or expected. Relevant relationships can also include ‘contracted research’ where the institution receives a grant and manages the grant funds and the individual is the principal or a named investigator on the grant.

Commercial Interest, as defined by ANCC, is any entity producing, marketing, re-selling, or distributing healthcare goods or 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 healthcare goods or services consumed by, or used on, patients. Nonprofit or government organizations, non-healthcare-related companies, healthcare facilities, and group medical practices are not considered commercial interests.

Individuals found to have a COI are not eligible to serve as a/the Nurse Planner but may be able to serve on the planning committee or as a presenter/author if measures are taken to resolve the COI. Employees or representatives of a commercial interest may not serve as a Planner of an educational activity, although they may be eligible to serve as faculty if measures are taken to resolve any potential conflict of interest.

1. Over the past 12 months, have you or your spouse/partner had a financial relationship with a commercial interest whose products or services may be relevant to the educational content that you will plan/present for this activity?

☐ NO ☐ YES – Provide details of relationship(s) below:

Check allthat apply

CATEGORY DESCRIPTION – Provide Names of Organizations & Relationship

☐ Employee e.g. salesperson, marketing, or education

☐ Royalty

☐ Stockholder

☐ Speakers Bureau

☐ Consultant

☐ Other

Section 4: Statement of UnderstandingI have taken every precaution to ensure that the presentation identified above will be evidence-based or based on the best available evidence and free from bias and promotion. Completion of the name and date below serves as the electronic signature of the individual completing this Conflict of Interest Form and attests to the accuracy of the information given above.

Name and Credentials: Date:

Section 5: Nurse Planner, Planning Committee Member ReviewThe Nurse Planner or member of the planning committee is responsible for ensuring completion and review of the Conflict of Interest form by each planner, presenter/faculty/author, and content reviewer, to document evaluation of actual or potential bias and conflict of interest.

BE COMPLETED BY THE NURSE PLANNER or MEMBER OF THE PLANNING COMMITTEE:This form must be reviewed by the Nurse Planner or member of the Planning Committee for this educational activity other than the RN completing it to verify the RN meets the following requirements to serve as a Nurse Planner:

1. Is currently licensed as a Registered Nurse2. Holds a baccalaureate or graduate degree in nursing3. Is not employed by and does not represent any commercial interest organization4. Has no COI (relevant relationship with a commercial interest as defined above)5. Is willing to work to ensure the content integrity of this educational activity

Nurse Planner resolution of potential Conflicts of Interest – check all that apply:☐Not Applicable-No relationship(s) with a commercial interest were disclosed☐Not Applicable-Relationship(s) disclosed were found not to be ‘relevant relationship(s)’ (explain in NOTES below)☐Relevant relationship(s) with a commercial interest were identified (COI exists):☐RN not eligible to serve as the Nurse Planner NOTES: Additional concern(s) for potential for bias that were not self–reported on this form AND resolution – if applicable:

Presenter/faculty/author and content reviewer resolution of potential Conflicts of Interest – check all that apply:

☐Not Applicable-No relationship(s) with a commercial interest were disclosed☐Not Applicable-Relationship(s) disclosed were found not to be ‘relevant relationship(s)’ (explain in NOTES below)

☐Relevant relationship(s) with a commercial interest were identified (COI exists)-ACTIONS TO RESOLVE COI:☐Removed individual from participating in all parts of this education activity☐Revised individual’s role in activity so the financial relationship was no longer relevant☐Not awarding contact hours for a portion or all of the education activity☐Review of educational activity for evidence of integrity/absence of bias by (name) AND

☐Presentation will be monitored to evaluate for commercial bias (document outcome in NOTES)☐Participant feedback will be reviewed to evaluate for commercial bias in the activity (document in NOTES)

☐Other procedure: NOTES:

Additional concern(s) for potential for bias that were not self–reported on this form AND resolution – if applicable:

Electronic Signature: An ‘X’ in the box below serves as the electronic signature of the Nurse Planner or Planning Committee member reviewing the content of this form and attests to the accuracy of the information given above.

☐ Name and Credentials: Date:

Attachment 3Attach a sample of your Certificate of Completion

Samples available online

Activity Provider NameAddress of Activity Provider

City State ZIP

Certifies that:

Participant First Name Last Name, Credentials

has received ( insert number) contact hours for successfully completing

Title of ActivityDate: Insert date of activity Location: Facility Name (Web address for online

programs) NEMSD Approval #: ____________ Address

City, State ZIP

This continuing nursing education activity was approved by the Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Authorized Signature (typically a Nurse Planner)

Attachment 4Attach any Commercial Support Agreement(s) if applicable

Sample available online

May use Northeast MSD template or the Commercial Interest Organization's preferred agreement.

Attachment 5Insert here a copy of the disclosures provided to learners prior to start of the activity or use this template. Your

disclosures must include items 1-5 and 6-7 if applicable. Complete the Action area and remove 6-7 if they do not apply

DISCLOSURES HANDOUT/FIRST SLIDE FOR PARTICIPANTS

Activity Title:Activity Date:

Disclosure Action1) Approval Statement This continuing nursing education activity was approved by the Northeast

Multistate Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

2) Learner Outcomes Insert Learner outcomes:

3) Criteria for Successful Completion

Insert participant requirements to receive contact hours.

4) Conflicts of Interest

Presence or absence of conflicts of interest for all individuals in a position to control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers) If COI is present, disclosure must include name of person, type of relationship, and name of commercial entity.

MUST CHOOSE ONE and delete the others:

This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest.

ORNo individuals in a position to control content for this activity has any relevant financial relationships to declare.

ORThe following individuals in a position to control content for this activity declare they have a commercial interest relationship relevant to the content of this activity and it has been resolved with the nurse planner.

_____NAME_____________ (insert the type of relevant financial relationship). Examples:Ann Jones, RN is on the Speaker's Bureau for XYZ Company.Ralph Emerson owns stock in XYZ Company

5) Commercial Support (Insert Name of Commercial Interest) providing financial or in-kind support for this activity and signed a commercial support agreement:

ORThere is no commercial support being received for this event.

6) Expiration date for Enduring Materials (if applicable)

Origination Date: insert the dateExpiration Date: insert the date (2 years after approval)

7) Joint Provider(s)(if applicable)

Note: Materials associated with the activity (marketing materials, advertising, agendas, and certificates of completion) must clearly indicate the Provider awarding contact hours and is responsible for adherence to ANCC criteria)

This activity is being jointly provided by [Insert Activity Provider Name] and [insert Joint Provider Organization's name(s)].

Attachment 6Attach a Sample of Participant Evaluation Form/Method


(Provider Unit Name)Title of Activity:

Activity Date:

EVALUATIONThe planning committee would like your opinion and comments on this educational activity. This will assist in planning future educational activities. Please leave the completed evaluation form with program personnel at the end of the activity.

QUALITY OF INSTRUCTION: (if multiple presenters, evaluate the following for each speaker/presenter individually)Please check the following criteria when rating the following speaker: Presenters Name, Credentials Excellent Good Fair Poor

Knowledge of subject

Organization and clarity of content

Effectiveness of teaching methods

LEARNING OUTCOMES: (if multiple outcomes, evaluate the following for each outcome individually)As a result of this activity, I was/will be able to (insert a learning outcome here): ☐YES ☐NO

If no, please explain: _____________________________________________________________________Were the presentation(s) free from commercial bias? ☐YES ☐NO

If no, please explain: _____________________________________________________________________As a result of this activity, please share at least one action you will take to change your professional practice/ performance: ________________________________________________________________________________________________________________________________________________________________ADMINISTRATIVE ARRANGEMENTS:

Please check the administrative arrangements as satisfactory or unsatisfactory. Satisfactory Unsatisfactory

Promotional information provided adequate information

Registration process was efficient

Scheduling of the activity met my needs

General comments about the program:

Suggestions for future program topics:

Thank you for coming.

Attachment 7Attach a Sample of Joint Provider Agreement


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