Accredited Approval Unit Individual Activity Application

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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Directions: 1. Applicants interested in submitting an individual educational activity for approval must first

complete the Individual Activity Applicant Eligibility Verification Form.2. After successful completion of the Individual Activity Applicant Eligibility Verification Form the

applicant must complete this application. The application should be completed by typing directlyinto the PDF fillable form and attaching all requested documents. For directions on how to attacha document within the application, please watch this video.

3. Applications must be submitted with payment to our Individual Activity Application Portal.4. If you have questions or need assistance with this process, please call 804-282-1808.

Application Fees: Individual Activity Application fees can be found here. Applications will not be reviewed until receipt of payment. All fees are non-refundable. Applicants are highly encouraged to submit payment electronically for the quickest processing time.

If you will pay by check, please submit your Individual Activity Application electronically first. Include the name of your organization and the name of your Individual Activity on your check, and mail payment to: Attn: VNA Accredited Approval Unit IAA Payment Virginia Nurses Association 2819 N. Parham Road, Suite 230 Richmond, VA 23294

Helpful Tips: • Is your activity continuing nursing education? If the learning activity is intended to build upon the educational and

experiential bases of the professional RN for the enhancement of practice, education, administration, research, ortheory development, to improve the health of the public and RNs’ pursuit of their professional career goals, then itis continuing nursing education.

• Review the Resources for completing an Individual Activity Application on the Individual Activity Webpage.• Review these videos on How to Complete an Individual Activity Application (Use the password: Apply):

1.Basic Activity Information3. Calculating the Number of Contact Hours

2. Conflict of Interest Assessment 4. The Educational Design Process

• Use this application to guide the planning of your educational activity. You will find it much easier to complete theapplication if it is used to facilitate the development of your activity rather than completed after you plan the activity.

• The Nurse Planner’s role is not to just “fill out the application”. The Nurse Planner is responsible for guiding theplanning process, ensuring that the activity is developed to address a gap in practice, that content is developedbased upon best available evidence, and that the activity is implemented in a manner that meets adult learnerneeds and that is free of bias. The Nurse Planner is accountable to VNA for ensuring all criteria are adhered to sothat the activity can be approved.

• Your educational activity should be developed to address a professional practice gap, which is a change, problem,or opportunity for improvement in practice. The planning committee must analyze the professional practice gapand determine if the activity will address a gap in knowledge, skill, and/or practice. In most cases, individualactivities are addressing an educational need of knowledge or skill. The planning committee then determines whatthe desired learning outcome is for the learner.

• The desired learning outcome is the overarching outcome you want learners to achieve after participating in youreducational activity. The desired learning outcome for your activity should be developed based on the professionalpractice gap and the educational need identified. The desired learning outcome should be written as a learningoutcome measure that identifies the target you hope learners will achieve. You should be able to measure whetherit is achieved using your evaluation method. Please note that the learning outcome measure is not a list ofobjectives for your activity. It is acceptable to have one overarching learning outcome measure for the activity.

• Advertising prior to approval: If you will be advertising this activity prior to approval, the following statement may beused: This activity has been submitted to the Virginia Nurses Association for approval to award contact hours. TheVirginia Nurses Association is accredited as an approver of continuing nursing education by the American NursesCredentialing Center’s Commission on Accreditation.

• Once approved, your activity may be provided as many times as you choose during the two-year approval periodas long as you do not make significant changes to the content or hours and you report any changes in faculty to VNA.

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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Basic Activity Information

Applicant’s Name (Organization or Individual):

Address or Web Address of Organization/Individual:

Organization Type:

� Hospital/Health System � Professional Association

� Home Health Agency � College/University

� Long Term Care Facility � Government Agency

� Healthcare Office/Practice � Continuing Education Company

� Business Providing Services to Healthcare Industry

� Other:

Title of Activity:

How many contact hours are you applying to award?

What type of activity are you providing? (Ex. Course, Conference, Webinar, Article/Manuscript):

Please provide further details on the activity:

� Provider-directed, provider-paced: Live activities (Ex. In-person course/webinar) • Date(s) of live activity:

• City & State where activity will be held:

� Provider-directed, learner-paced: Enduring material (Ex. Recorded webinar, article) • Start date of enduring material:

• Expiration/end date of enduring material (Cannot exceed 2-year approval period,

but may be any length up to 2 years):

• Please identify the date you will review the material to determine if updates arerequired (You are required to ensure enduring content remains current and relevant. If necessaryduring the 2-year approval period, you are required to remove the enduring material fromcirculation to update the content.):

� Blended activity: • Date(s) of pre-work and/or post-activity work:

• Date(s) of live portion of activity:

• City & State where live activity will be held if in person:

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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Nurse Planner Contact Information for this Activity

Name and credentials (please list educational degrees- must have a baccalaureate degree or higher in nursing):

Email address:

Phone Number:

The VNA Accredited Approval Unit will use the email address provided for the Nurse Planner for all communication regarding the status of this application.

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

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application ANCC 2015 Criteria

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Name and Credentials of all planners, presenters, faculty, authors, content reviewers

Complete the table below for each person in a position to control content of the educational activity and include name, credentials, educational degree(s), role on the planning committee, and if they have a commercial interest relationship. Planning committees must have one Nurse Planner and one other planner with subject matter expertise for the activity being offered in order to plan each educational activity. The Nurse Planner is responsible for adherence to the ANCC criteria. There should be only one individual designated as the Nurse Planner, but there may be additional nurses on the planning committee. The Nurse Planner may also be the content expert, but there must be at least one other individual on the planning committee. You may submit an additional spreadsheet if needed.

Name of individual and credentials

Individual’s role in the activity Ex. Nurse Planner, Planning Committee, Content Expert, Content Reviewer, Presenter, Author (Be sure to identify the Content Expert)

Planning Committee Member (Yes/No)

Name of Commercial Interest Relationship (if any-see Conflict of Interest section for definition)

Nature of Commercial Interest Relationship (if any-see Conflict of Interest section for definition)

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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Conflict of Interest Assessment

The Nurse Planner is responsible for assessing all individuals with the ability to control the content of the educational activity for a conflict of interest, resolving any conflicts of interest, and documenting this process. A conflict of interest exists when an individual, with the ability to control the content, has a financial relationship with a commercial interest organization (a company who produces, markets, resells, or distributes healthcare goods/services consumed by or used on patients) and the products/services of this organization are related to the content of the educational activity.

Please attach Conflict of Interest Forms for each individual in a position to control the educational content (e.g. planners, presenters, faculty, authors, and/or content reviewers). These can be found on the Individual Activity Webpage.

OR If the educational content of the activity is NOT related to any healthcare products or services consumed by or used on patients (ex. Leadership Development, Preceptor Development, Legislative Advocacy, Workplace Violence) then there is no potential for a conflict of interest. If your activity falls in this category, complete the attestation below.

� Conflict of Interest Forms are attached for all individuals in a position to control the educational content. *IF you are planning an interprofessional continuing education activity the CME Disclosure of Financial Relationships Form may be attached for each individual in a position to control the educational content. The Nurse Planner must also attach an attestation stating they have reviewed the Disclosure of Financial Relationship forms and document if there are any conflicts present and the resolution method if applicable.

OR

� I attest that the content of this educational activity is not related to any healthcare products or services consumed by or used on patients and therefore there are no conflicts of interest for any individual in a position to control the educational content.

Nurse Planner Signature:

Date:

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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Educational Design Criteria

A. What is the problem/opportunity/change that has created the need for this educationalactivity? (Please provide a 1-2 sentence response.)

B. Provide a brief summary of the evidence that supports this problem/opportunity/changeexists. (Focus on the evidence that demonstrates the problem exists and not on the content of theactivity. Why is this happening and how do you know it could be done better?)

C. What is the educational need that this activity is designed to address?� Gap in Knowledge (The learner does not know.)� Gap in Skills (The learner does not know how.)� Gap in Practice (The learner does not know how to implement in practice.)

D. Who is the target audience for this activity?

E. What is the measureable learning outcome for the learner at the end of this activity?(What do you want the learner to know, or be able to do, or apply to practice, after participating in theactivity and how will you know if you are successful? Examples: 100% of participants will demonstrateknowledge of basic arrhythmia interpretation by passing a post-test with a score of 80% or higher;Learners will identify 1 piece of knowledge related to patient engagement that they will use to changeor enhance their practice; 75% of participants will demonstrate skill with de-escalation throughparticipation in a simulation. -Please note that the measurable learning outcome is not a list ofobjectives.)

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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F. Content of Activity: Please provide a paragraph description or outline summarizing the content tobe provided. (If this is a conference, please describe how the sessions will contribute to meeting theoverall learning outcome. Please do not provide a description of each individual session.)

If the activity is 2 hours or longer, please also submit the agenda for the entire activity.

� Agenda is attached.

What is your rationale for determining the amount of contact hours? (ex. agenda/content outline, complexity of content, historical data, pilot study, Mergener Formula)

G. Please provide current and evidence based resources that will support thedevelopment of the content of this educational activity. List the authors, titles, and dates ofpublication. Resources should be from the past 5-7 years. If a content expert will be a resource,please also ensure there is another evidence based resource to support the content. It is notrequired to provide an exhaustive list of content resources.

H. Please describe the learner engagement strategies that will be used to activelyinvolve the learner in the activity. Examples of engagement strategies include discussion,reflection, skills practice, case studies, role play/simulations, gaming etc. PowerPoint and lecture arenot engagement strategies.

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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I. Criteria for Awarding Contact HoursPlease check all that apply. Please ensure this matches your disclosures attached in Section M.

☐ Attendance for a specified period of time (e.g., 100% of activity, or miss no more than10 minutes of activity) - Describe:

☐ 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:

J. Please describe your Evaluation Method. How will you evaluate if the learner has gainedknowledge, is able to implement a skill, or will apply what has been learned to practice? Yourevaluation should determine if the learning outcome identified in E. has been achieved at the level ofidentified educational need (knowledge, skill, or practice). Evaluation can be conducted in variousways, including through observation of participants in engagement strategies throughout the program,post-test, performance in a simulation or other skill demonstration, end of program discussion, verbalor written response to specific questions, etc. An evaluation form can be used but is not arequirement.

K. Will this activity be Jointly Provided? Joint Providership is when two or more organizationsplan, develop, and implement an educational activity together. You may not jointly provide aneducational activity with a commercial interest organization.

� No � Yes

o Joint Provider Organization(s):

Please note that if you are jointly providing this activity, the organization completing this application is considered the Provider of the educational activity and the other organization is the Joint Provider. The Provider is the organization that is approved to award nursing contact hours and is responsible for adherence to the ANCC criteria. The Joint Provider organization must have an individual from their organization on the planning committee. All materials (marketing, advertising, agendas, and certificates) must clearly indicate the organization that is the Provider.

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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L. Will Commercial Support be provided for this activity? Commercial Support is financial orin-kind contributions given by a commercial interest that are used to pay for all or part of the costs ofa CNE activity.

� No � Yes

o If the educational activity will receive commercial support, a Commercial Support Agreementmust be completed, signed, and dated by the commercial interest organization and provider ofthe educational activity. If multiple commercial interest organizations will provide support, anagreement is required for each commercial interest organization. If you are unsure as towhether the organization providing support is a commercial interest, please refer to thedefinition of a commercial interest provided in the ANCC Content Integrity Standards or contactthe VNA. A Commercial Support Agreement may be found on the Individual Activity Webpage.A Letter of Agreement provided by the Commercial Interest may fulfill this requirement if itmeets the standards outlined in the ANCC Content Integrity Standards and is signed by thecommercial interest and provider organization.

� Commercial Support Agreement Attached

M. DisclosuresLearners must receive required educational disclosures prior to the start of the educational activity. Disclosures can be provided via printed materials (ex. agenda), verbally, via presentation slide, etc. A sample disclosure document, with appropriate wording, is provided on the Individual Activity Webpage.Required educational disclosures:

1. Activity approval statement written as: This continuing nursing education activity was approved by the Virginia Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

2. Criteria for successful completion in order to receive contact hours.3. Presence or absence of conflicts of interest for all individuals in a position to control content. If

a conflict of interest is present, the disclosure must include the name of the person, type of relationship, and name of the commercial entity.

4. Commercial support (if applicable)5. Expiration date of enduring materials (if applicable)6. Joint providership (if applicable)

How will you provide disclosures to the learner?

� Attach a copy of the disclosures that will be provided to learners.

Virginia Nurses Association Accredited Approval Unit Individual Educational Activity Application

ANCC 2015 Criteria

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N. Certificate/Documentation of CompletionThe certificate must include:

1. Title and date of the educational activity2. Name and address of the provider of the educational activity (web address is

acceptable)3. Number of contact hours awarded4. Space for participant’s name5. Activity approval statement: This continuing nursing education activity was approved

by the Virginia Nurses Association, an accredited approver by the American NursesCredentialing Center’s Commission on Accreditation.

A sample certificate is provided on the Individual Activity Webpage.

� Attach a copy of the certificate that will be provided to learners that participate in this educational activity.

O. Post Activity Reporting & Recordkeeping• The VNA requires submission of a Summative Evaluation of your activity within 30 days

of the activity. The Summative Evaluation should include results related to themeasurable learning outcome, learner feedback, what was effective, what could beimproved, and any changes that will be made to future activities based on this program.You will also be asked to report the total number of learners participating in the activity,the total number of RNs who participated in the activity, the amount of commercialsupport received, and intent to repeat the activity. Please submit this to our SummativeEvaluation Portal.

• You are required to maintain secure and confidential records of this activity for aminimum of 6 years from the date of delivery. The records maintained must include: theapplication file, evaluation summation, and a record/roster of all participants and theamount of contact hours awarded to each participant.

Attachments Checklist: For instructions on attachments, click here.

� Conflict of Interest Forms for all individuals in a position to control the educational

content (If required)

� Agenda (If activity is greater than 2 hours)

� Commercial Support Agreement (If applicable)

� Disclosures that will be provided to the learner

� Certificate of Completion

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Virginia Nurses Association

Conflict of Interest Form

2015 Criteria

Title of Educational Activity:

Education Activity Date:

Role in Educational Activity: (Check all that apply) Nurse Planner

Content Expert

Faculty/Presenter/Author Content Reviewer

Planning Committee Member

Section 1: Demographic Data

Name with Credentials/Degrees: ________________________________________________________

If RN, Nursing Degree(s): AD Diploma BSN Masters Doctorate

Address: ___________________________________________________________________________

Phone Number: ______________________________ Email Address: ________________________

Current Employer and Position/Title: _____________________________________________________

Section 2: Conflict of Interest

The potential for conflicts of interest 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. The Nurse Planner is

responsible for evaluating the presence or absence of conflicts of interest and resolving any identified

actual or potential conflicts of interest during the planning and implementation phases of an educational

activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself

or herself from the role as Nurse Planner for the educational activity.

*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.

Commercial Interest Organizations are ineligible for accreditation.

An organization is NOT a Commercial Interest Organization* if it is:

• A government entity;

• A non-profit (503(c)) organization;

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• A provider of clinical services directly to patients, including but not limited to hospitals,

health care agencies and independent health care practitioners;

• An entity the sole purpose of which is to improve or support the delivery of health care to

patients, including but not limited to providers or developers of electronic health

information systems, database systems, and quality improvement systems;

• A non-healthcare related entity whose primary mission is not producing, marketing or

selling or distributing health care goods or services consumed by or used on patients.

• Liability insurance providers

• Health insurance providers

• Group medical practices

• Acute care hospitals (for profit and not for profit)

• Rehabilitation centers (for profit and not for profit)

• Nursing homes (for profit and not for profit)

• Blood banks

• Diagnostic laboratories

(*Reference: Accreditation Council for Continuing Medical Education (ACCME) Standards of

Commercial Support, August 2007 (www.accme.org) - ANCC’s definition is intended to ensure

compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and

Educational Activities and consistency with the ACCME definition)

All individuals who have the ability to control or influence the content of an educational activity must

disclose all relevant relationships** with any commercial interest, including but not limited to members of

the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships

must be disclosed to the learners during the time when the relationship is in effect and for 12 months

afterward. All information disclosed must be shared with the participants/learners prior to the start of the

educational activity.

**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products

or services of the commercial interest 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, excluding diversified mutual funds), grants, contracts, or other

financial benefit directly or indirectly from the commercial interest.

• Financial benefits may be associated with employment, management positions, independent

contractor relationships, 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 from the commercial interest.

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Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?

Yes No

If yes, complete the table below for all actual, potential or perceived conflicts of interest**:

Check all that apply

Category Description

Salary

Royalty

Stock

Speakers Bureau

Consultant

Other

** All conflicts of interest, including potential ones, must be resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity.

Section 3: Statement of Understanding

Completion of the line below serves as the electronic signature of the individual completing this

Biographical/Conflict of Interest Form and attests to the accuracy of the information given above.

________________________________________________________ _________________________

Typed or Electronic Signature: Name and Credentials (Required) Date

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Section 4: Conflict Resolution (to be completed by Nurse Planner)

A. Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply)

Not applicable since no conflict of interest.

Removed individual with conflict of interest from participating in all parts of the educational activity.

Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the

educational activity.

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

Undertaking review of the educational activity by Nurse Planner/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.

Undertaking review of the educational activity by Nurse Planner/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.

Other - Describe:

Nurse Planner Signature (* If form is for the activity Nurse Planner, an individual other than

the Nurse Planner must review and sign the form).

Completion of the line below serves as the electronic signature of the Nurse Planner reviewing

the content of this Conflict of Interest Form

________________________________________________________ __________________

Typed or Electronic Signature: Name and Credentials (Required) Date

ANCC IA Commercial Support Agreement VNA 1.2018 Page 1 of 2

Virginia Nurses Association Individual Activity Applicant

Commercial Support Agreement

A commercial interest, as defined by the American Nurse's Credentialing Center (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.

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

Note: Organizations providing commercial support may not provide or joint provide an educational activity.

Title of Educational Activity:

Activity Location (if live): Activity Date (if live):Name of Commercial Interest Organization:

Name of Individual Activity Applicant:

Total amount of Commercial Support:

Complete description of all Commercial Support provided including both financial and in-kind support:

Please check all that apply:

Unrestricted

Restricted*o Speaker honorariao Speaker expenseso Mealo Other (please list):

* Commercial interest may request that funds be used to support a specific part of an educational activity. TheIndividual Activity Applicant may choose to accept the restriction or not accept the commercial support. TheIndividual Activity Applicant maintains responsibility for all decisions related to the activity as described below.

Terms and Conditions

1. All organizations must comply with the ANCC Content Integrity Standards for Industry Support in Continuing Educational Activities which is available on the ANCC Accreditation web page.

2. This activity is for educational purposes only and will not promote any proprietary interest of a Commercial Interest organization providing financial or in-kind support.

▪ The CIO will not recruit learners from the educational activity for any purpose

3. The Individual Activity Applicant is responsible for all decisions related to the educational activity. The Commercial Interest organization providing financial or in-kind support may not participate in any component of the planning process or implementation of an educational activity, including:

ANCC IA Commercial Support Agreement VNA 1.2018 Page 2 of 2

▪ Assessment of learning needs and professional practice gap▪ Learning outcomes▪ Selection or development of content▪ Selection of planners, presenters, faculty, authors and/or content reviewers▪ Selection of teaching/learning strategies▪ Evaluation methods

4. The Individual Activity Applicant will make all decisions regarding the disposition and disbursement of commercial support in accordance with ANCC criteria.

5. All commercial support associated with this activity will be given with the full knowledge and approval of the Individual Activity Applicant. No other payments shall be given to any individuals involved with the supported educational activity.

6. Commercial support will be disclosed to the participants of the educational activity.

7. Commercial Interest Organizations may not exhibit, promote or sell products or services during the introduction of an educational activity, while the educational activity takes place or at the conclusion of an educational activity, regardless of the format of the educational activity.

Statement of Understanding

An “X” in the boxes below serves as the electronic signatures of the representatives duly authorized to enter into agreements on behalf of the organizations listed and indicates agreement of the terms and conditions listed in the Commercial Support Agreement above.

Individual Activity Applicant Name:

Address:

Name of Representative:

Email Address:

Phone Number:

Fax Number:

__________________________________ Electronic Signature (Required) Date:

Completed By: (Name and Credentials)

Commercial Interest Name:

Address:

Name of Representative:

Email Address:

Phone Number:

Fax Number:

__________________________________ Electronic Signature Type Name (Required) Date:

Completed By: (Name and Credentials)