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NEW YORK CITY HEALTH AND HOSPITALS CORPORATIONCONTINUING NURSING EDUCATION PROGRAM APPLICATION

forAccreditation of Continuing Nursing Education Program Activity

Corporate Nursing Services - New York City Health and Hospitals Corporationan Approved Provider Unit of Continuing Nursing Education by

The New Jersey State Nurses Association

EDUCATIONAL PROGRAMS ARE ACTIVE FOR TWO YEARS

Educational Activity Title:      

Type of Activity: Provider-paced Activity (Live)

Date(s) of Presentation:      

Name of Educational Activity Provider:      

Address for Correspondence:      

Name of Primary Contact: Name Title Telephone Number Fax Number Email

Number of Contact Hours Requested (Divide the total minutes by 60 round decimals down to the nearest tenth or one hundredth)

Total Number of MinutesTotal Number of Contact Hours

Continuing Education Credits Cannot Be Granted Retroactively

Complete applications should be received at least 4 business weeks (20 days) prior to the date of the first presentation of the CNE activity. Applications submitted less than 3 business weeks (15 days) prior to presentation date may not complete the review process for approval to award continuing educational credits. Applications submitted less than 3 weeks (15 days) prior to presentation date will not be reviewed.

Submit hard copy to: 125 Worth Street Submit electronic copy to: Alfreda.weaver@nychhc.org 4th Floor Suite 418

New York, NY 10013Attn: Alfreda Weaver

For questions concerning this application, please call (212) 442-3621

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A. Planning Committee (must include at least two RNs - one from the Approved Provider Unit and one other RN). Planning Committee must represent the following areas: relevant content expert, the target audience & responsibility for adherence to the ANCC criteria. A Nurse Planner must have education or experience in the field of education or adult learning. Please list the name, degrees, and credentials and attach a biographical data form with the additional required information. CVs and résumés are not accepted.

Educational Activity Planners

Name Degree Credentials Area of Representation

Nurse Planner Approved Provider Unit

Alfreda Weaver Nursing BSN, MSN ANCC Compliance

Activity Lead Nurse PlannerNurse Planner

Nurse Planner

Other Planner

BIOGRAPHICAL DATA/VESTED INTERESTS FORMS FOR EACH MEMBER OF THE PLANNING COMMITTEE ARE ATTACHED

B. Target Audience and Needs Assessment

1. Provider-paced Learning Activity Target Audience and Needs Assessment

Identify the target audience expected to attend: Level of Education: LPN___ Diploma___ Associate___ Baccalaureate___ Master___

Practice Area: Acute Care___ Critical Care___ Peri-Op___ Med/Surg___ Peds___ Psych___ OB/GYN___ Community Health___ Education___ Administration___ Advance Practice___ Other_______________________________________

Check the best description of type of needs assessment used (Please indicate all that apply): Formal needs assessment Learners/Management requested event Quality studies/incident reports &/or PI Data indicated need Trends in literature, law, and health care indicated need Other (describe):      

2. Describe the process used to identify the gap(s) in knowledge:      

C. Educational Activity Overview: Purpose Statement / Goal of Learning ActivityThe purpose statement is a general statement of intent. It reflects the rationale for the activity and for how it qualifies as continuing nursing education

The following information must be supplied:

1. Has this educational activity been submitted for continuing education credits in disciplines other than nursing? No       Yes       If yes, please describe_________

2. Indicate source of supporting evidence for needs assessment data. (Check all that apply. Provider must be able to access and/or submit this information upon request.)

     Annual employee survey     Literature Review     Periodic surveys of stakeholders or learners     Quality Data     Requests (e.g., via phone, in person or by email)     Written evaluation summary requests     Other - Describe:           Needs assessment data is attached or available upon request.

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(e.g., survey data, reference in literature, QI data, etc.)Purpose Statement / Goal of Learning Activity

(Use the attached Educational Activity Overview table to supply items 2-6)

3. Objectives:Indicate what the participant will be able to do at the conclusion of the activity. Objectives should be written in measurable terms given the time frame and teaching method. An average of 1-2 objectives per hour is realistic.

4. Content:Itemize key points that will be addressed with each objective. Content must be more than a restatement of the objective and must be related to the objective.

5. Time Frame:Indicate the number of minutes for each objective for live presentations. See Section J for independent studies.

6. Presenter:List the faculty who will be addressing each objective (this is not applicable for content specialists).

7. Teaching Methods:List the methods, strategies, materials, and resources to be used by faculty to cover each objective.

D. 1. Presenters/Content Specialists List the names, degrees, and credentials of each presenter/content specialist below. A Biographical Data and a Vested Interests form must be attached for each presenter.

Name Credentials Email Address

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What gap in knowledge, skills, attitude, or practice will be addressed?      How will nurses or clients benefit from this activity?      Purpose Statement:      

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2. Learners will be informed of presenters’ declaration of vested interests or their lack of vested interests, as well as presenters’ discussion of off-label use by (check all that apply):

Announcement at the beginning of the event/session (if verbal disclosure is made, there must be a written verification on the part of the sponsor who was in attendance, which attests that a verbal disclosure did occur, and that identifies the contents of the verbal disclosure. This must be kept in the educational activity file)

Information provided on advertising Information on electronic slides Information provided on handouts Signs placed inside or outside of presentation room Other (describe):

3. Is there a conflict of interest with any of the planners or presenters of this activity? Yes No

If yes how was conflict resolved? _______________________________________________________*Participants must be informed of resolution of any conflict of interest

E. Co-providership (Planning, developing, and implementing an educational activity by two or more organizations or agencies. A commercial interest may NOT be a co-provider).

This activity WILL NOT be co-provided This activity WILL be co-provided *

* If this activity will be co-provided, a written agreement between the provider and the co-provider(s), that identifies the responsibilities, must be included. The primary provider must retain responsibility for the following:

1. Determination of objectives and content2. Selecting faculty/presenters3. Awarding of contact hours4. Recordkeeping for this activity5. Evaluation6. Management of any commercial support or sponsorship

The co-provider(s) may be involved in planning, advertising, registration, accommodations, etc…

F. Commercial Support /Sponsorship (Support – money or ‘in kind’ services– received from commercial interests. Commercial Interest: any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Exceptions are made for non-profit or government organizations and non-health care related companies.) PLEASE COMPLETE Questions 1-4

This activity HAS NO financial commercial support This activity HAS NO “services in-kind” commercial support This activity HAS commercial support * This activity HAS “services in-kind” commercial support * This activity HAS received support from entities other than commercial interests.

* If the activity has commercial support, please complete the following items and check all that apply:

1. Commercial support has been provided by the following (list the names of companies):

1.

2.

3.

Provider of continuing nursing education attests that the following decisions were made free from control of a commercial interest:

Identification of continuing nursing education needs

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Determination of educational objectives Selection and presentation of content Selection of all persons and organizations that will be in a position to control the content of the

activity Selection of educational methods Evaluation of the activity N/A

2. Learners will be informed about commercial support, or the absence, by (when commercial products are displayed, participants will also be advised that approved status refers only to its continuing nursing education activities and does not imply NJSNA or ANCC Commission on Accreditation endorsement of any commercial product):

Information provided on advertising material Announcement at the beginning of the event/session (if verbal disclosure is made, there must be a

written verification on the part of the sponsor who was in attendance, that attests that a verbal disclosure did occur and that identifies the contents of the verbal disclosure. This must be kept in the educational activity file)

Information on handouts given at the start of the event/session A sign displayed in the exhibit area Other (describe):

3. Written Agreement Documenting Terms of Support (required)

N/A Written agreement specifies the source of the commercial support Written agreement identifies the terms, conditions, and the purposes of the support Written agreement is signed by both the educational activity sponsor and by the source of

commercial support

4. Amount of financial support: $

In-Kind Support: PLEASE COMPLETE Questions 1-4

1. In-Kind support has been provided by the following (list the names of companies):

1.

2.

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Provider of continuing nursing education attests that the following decisions were made free from control of a commercial interest:

Identification of continuing nursing education needs Determination of educational objectives Selection and presentation of content Selection of all persons and organizations that will be in a position to control the content of the

activity Selection of educational methods Evaluation of the activity N/A

2. Learners will be informed about In-Kind support, or the absence thereof, by: (when commercial products are displayed, participants will also be advised that approved status refers only to its continuing nursing education activities and does not imply NJSNA or ANCC Commission on Accreditation endorsement of any commercial product):

Information provided on advertising material Announcement at the beginning of the event/session (if verbal disclosure is made, there must be a

written verification on the part of the sponsor who was in attendance, that attests that a verbal disclosure

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did occur and that identifies the contents of the verbal disclosure. This must be kept in the educational activity file)

Information on handouts given at the start of the event/session A sign displayed in the exhibit area Other (describe):

3. Written Agreement Documenting Terms of Support (required)

N/A Written agreement specifies the source of the commercial support Written agreement identifies the terms, conditions, and the purposes of the support Written agreement is signed by both the educational activity sponsor and by the source of

commercial support

4. Value of In-Kind Support: $

G. Evaluation

1. Method(s) of evaluation to be used (check all that apply):

Completed Evaluation Tool (required for all events) Knowledge enhancement (Specify:     ) Pre-test/Post-test Skill and attitude change (Specify:     ) Change in practice/performance (Specify:     ) Relationship of the practice change to quality of service (Specify:     ) Return Demonstration Other (describe):      

2. Evaluation of Learning Activity:

A. Provider-paced Activities (Classroom, Conference, and live Webinar/Webcast):

Submit a copy of the evaluation tool(s) to be used for the event. (Form D):

3. How will evaluation data be used to (check all that apply):

Revise future presentations of this course Create new programs Other (describe):      

4. Identify how feedback will be provided to the learner (Check all that apply)

Question and answers during activity Return results of testing Follow-up communication Other (describe):      

B. Learner-paced Activities (Learning Modules, Web-Based Programs, Webinars/Webcast, CD etc):

Describe how the effectiveness of the independent study was evaluated, the results of the evaluations, and the changes/revisions made to the program based on the evaluation: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Submit a copy of the evaluation tool(s) to be used for the event. (Form E)

H. Verification of Participation and Successful Completion

1. Indicate how attendance/participation will be verified (check all that apply)

Sign-in/attendance sheets

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Completion of registration forms Other (describe):      

2. Criteria for successful completion include (check all that apply):

Attendance at the entire event Completion & Submission of the evaluation form Achieving a passing score on the post-test (passing score = _       _ %) Achieving minimum competency level on skills demonstration (provide a sample of the skills demonstration checklist/assessment rubric) Completion of a self-study packet Credit will be given for partial attendance (separate sessions, not less than 0.5 contact hours) Other (describe):      

3. Process utilized to inform participants of criteria/requirements for completion (check all that apply):

Information on the brochure/advertising materials (note: if this line is checked, this information must be included on advertising materials) Verbal statement at the beginning of the event Written information on handouts/website Other (describe):

4. Submit a sample of the Certificate of Attendance. It must include:a. Name of participantb. Number of contact hours awardedc. Name and address of the sponsoring agencyd. Title and date of the activitye. Learner-paced Activities (Learning Modules, Web-Based Programs, Webinars/Webcast, CD, etc.) &f. Official approval statement: To be provided once activity is approved to award contact hours

I. Recordkeeping System

Provider –Paced Learning Activity:

All correspondence, a complete copy of the application with all attachments and corrections, records of attendance, summative evaluation(s), co-providership agreements, commercial sponsorship agreements, and contact hours will be maintained by the Approved Provider Unit in a retrievable file which is accessible to authorized personnel and that meets the NJSNA criteria.

All records will be retained for six years and depict how confidentiality will be maintained:

Record access is limited to authorized personnel. Electronic files are password protected. Physical files are stored in a locked location. Identity authentication is required for participants to request their information from the CNE files. Other. Please describe:      

Learner-Paced Learning Activity:

All correspondence, a complete copy of the application with all attachments and corrections, records of attendance, summative evaluation(s), co-providership agreements, commercial sponsorship agreements, and contact hours will be maintained by the Approved Provider Unit in a retrievable file which is accessible to authorized personnel and that meets the NJSNA criteria.

All records will be retained for six years and depict how confidentiality will be maintained:

Record access is limited to authorized personnel. Electronic files are password protected. Physical files are stored in a locked location. Identity authentication is required for participants to request their information from the CNE files. Include all Pilot Testing Process Materials: (Required)

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J. Contact Hour Calculation

What was the method for calculating the contact hours (check all that apply):

Time spent in class divided by 60 Historical Data Word Count/Complexity Calculation Peer Review Pilot Study Other (describe):      

K. Advertising

Include the activity’s target audience, goals, and learning objectives on the advertising.

Identify the presence or absence of commercial support, Conflict of Interest, Discussion of Unlabeled Use

Submit a copy of the advertising material(s). Document must be attached. It must include the following submission statement concerning NJSNA approval: This (type of learning activity) has been submitted to Corporate Nursing-New York City Health and Hospitals Corporation for approval to award ___ contact hours. New Jersey State Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center.

Enduring documents (self-learning texts, CDs, tapes, computer-assisted or computer-based learning materials) must also include a statement that explains how long contact hours will be awarded for an activity (maximum 1 year). This statement must appear on all marketing materials and on the educational materials.

L. ATTESTATION STATEMENT

I, the undersigned, attest that as a provider of this educational activity we (planners & presenters) will comply with all applicable local, regional, state, or national laws and regulations and operate business in an ethical manner.

Signature: ________________________________________ Date: _______________

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NEW YORK CITY HEALTH AND HOSPITALS CORPORATIONCONTINUING NURSING EDUCATION PROGRAM

FORM A: Biographical Data/Vested Interests Form

Administrator Planner PresenterName (with degrees and credentials):      Street Address:      City, State, Zip Code:      Daytime Telephone:      Fax:      E-mail Address:      

Educational Background (include basic preparation through the highest degree held):

Degree Year Awarded Institution(Name, City, State) Major Area of Study

                       

                       

                       

                       

Planners – describe your familiarity with the target audience or familiarity with education and adult learning principles:      

Presenters – describe your expertise in this topic:      

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FORM B: Disclosure and Resolution of Vested Interests

Having a relationship with a commercial interest does not prevent a speaker from making a presentation, but the audience must be informed of this relationship prior to the start of the activity and any potential conflict must be resolved.

The planners and faculty must make full disclosure indicating whether the planner, faculty/moderator or content specialist and/or his/her spouse or partner have any financial, professional, or personal relationships with commercial interests, or have had any financial, professional, or personal relationships with commercial interests within the past 12 months.

An entity has a commercial interest if:1. It produces, markets, sells, or distributes health care goods or services consumed by or used on patients; OR2. It is owned or operated, in whole or in part, by any entity that produces, markets, sells, or distributes health care goods or

services consumed by or used on patients

An entity is NOT a commercial interest if:1. It is a government entity; 2. It is a non-profit (503c) organization; OR3. It is a non-healthcare related entity

A. Is there a financial, professional, or personal relationship that could potentially bias the content of the activity? Yes No

If yes, please list the companies and type of relationship:Relationship Name of Commercial Entity or Source of Potential Bias

Research Support      Speakers’ Bureau      Consultant      Shareholder      Other Support      Other      

1. If yes, you must disclose this information during your presentation. How will you do this? Information provided in audiovisuals (slides, overhead, etc.) Information provided on handouts Other: Please describe (if verbal disclosure is made, there must be a written verification on the part of the sponsor who

was in attendance, which attests that a verbal disclosure did occur and that identifies the contents of the verbal disclosure):      

2. How have you resolved this potential conflict of interest? The conflict has been discussed with the individual who is now aware of and agrees to our policy. Presenter has signed a statement that says s/he will present information fairly and without bias. An RN with minimum of a baccalaureate degree will monitor session to ensure conflict does not arise. Other. Please describe:      

Disclosure of Discussion of Unlabeled UseIs there intent to discuss the use of a product/medication for a purpose other than that for which it was approved by the FDA.

B. Is there a discussion of unlabeled uses? Yes No

1. If yes, you must disclose this information during your presentation. How will you do this? Information provided in audiovisuals (slides, overhead, etc.) Information provided on handouts Other: Please describe:      

The signature is required (faxed, scanned, handwritten, or a digitally verified signature are acceptable)

________________________ _____________ ___     ________________Signature Date

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NEW YORK CITY HEALTH AND HOSPITALS CORPORATIONCONTINUING NURSING EDUCATION PROGRAM

OBJECTIVES CONTENT (Topics) TIME FRAME PRESENTER TEACHING METHODSLearner-oriented, with at least one measurable behavioral verb per objective.

Outline of the content to be covered that will enable the learners to meet their

objectives

Indicate the time frame for each

objective.

List the faculty or content expert for each objective.

Describe the teaching methods, strategies, materials, and resources

for each objective.

                             

                             

                             

                             

NEW YORK CITY HEALTH AND HOSPITALS CORPORATIONApp2014

FORM C: EDUCATIONAL ACTIVITY OVERVIEW

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CONTINUING NURSING EDUCATION PROGRAM

OBJECTIVES CONTENT (Topics) TIME FRAME PRESENTER TEACHING METHODSLearner-oriented, with at least one measurable behavioral verb per objective.

Outline of the content to be covered that will enable the learners to meet their

objectives

Indicate the time frame for each

objective.

List the faculty or content expert for each objective.

Describe the teaching methods, strategies, materials, and resources

for each objective.

                             

                             

                             

                             

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FORM C: EDUCATIONAL ACTIVITY OVERVIEW

NEW YORK CITY HEALTH AND HOSPITALS CORPORATIONCONTINUING PROFESSIONAL EDUCATION

Title: Activity Code:

Date: Location:

Circle the number that best describes your rating of each statement Poor Fair Good Excellent1. To what extent did the objectives relate to the overall goal &

purpose of this learning activity? 1 2 3 4

2. To what extent were the following objectives of this learning activity achieved? 1 2 3 4

a) 1 2 3 4

b) 1 2 3 4

c) 1 2 3 43. The training material was practical to my job? 1 2 3 4

4. Training material was presented clearly & accurately? 1 2 3 4

5. Teaching strategies were appropriate? 1 2 3 4

6. The degree of confidence I have that I will use the knowledge from this training? 1 2 3 4

7. Rate the effectiveness of each presenter by circling a number(1= Poor, 2 = Fair, 3= Good, 4 = Excellent)

Knowledge of Subject

Presentation orderly and

understandable

Effective use of teaching

tools

Small groups, role playing & assignments

a. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

b. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

c. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

8. To what extent were the teaching strategies appropriate? 1 2 3 4

9. To what extent did audio visual presentations and written materials contribute to the program? 1 2 3 4

10. To what extent was the time allotted for the completion of the learning activity sufficient? 1 2 3 4

11. Overall assessment of this educational activity? 1 2 3 4

12. Was this program fair, balanced, and free of commercial bias? Yes No

13. Location and environment was conducive to learning? Yes No

14. The provider of the activity has disclosed in writing or verbally the conflict of interest or lack thereof declared by the planners and presenters/content specialists? Yes No

PARTICIPANT EVALUATION & ATTENDANCE ATTESTATION TYPE: CME ☐ CNE ☐What changes will you make in your practice based on this learning activity? __________________________________

What did you like most about this learning activity? _______________________________________________________

What did you like least about this learning activity? ________________________________________________________

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Email: _______________________________________ Name: ________________________________

Marketing Materials Guidelines

Purpose – you must include a purpose as well as objectives

Objectives – must include 2-3 objectives

Speaker - must state speakers’ names

Speaker Disclosure — it has to be noted on the marketing material “Speaker(s) has declared

that she/he has nothing to disclose.”

Commercial Support - is part of the application as well as the marketing material—on your

marketing material, you have to note, “There is no commercial support for this activity.” Or

whatever Comm. Support is received for the activity.

Individual Accreditation statement – This activity has been submitted for approval to award

contact hours. New Jersey State Nurses Association is accredited as an approver of continuing

nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Provider Accreditation statement – New York City Health and Hospitals Corporation is an

approved provider of continuing nursing education by New Jersey State Nurses Association, an

accredited approver by the American Nurses Credentialing Center's Commission on

Accreditation. P# NYP264-10/24/14

Disclaimer - It is the endorsement statement--This is the statement that must always be

included “Accredited status does not imply endorsement by NJSNA, New York City Health and

Hospitals Corporation, or ANCC of any commercial products or services.

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Continuing Nursing Education

CME/CNE credits or Certificate of Attendance is awarded upon completion of legibly signed and submitted evaluation form.PLEASE PRINT LEGIBLY

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FORM E: ADVERTISING MATERIAL for a Submitted – Provider-Paced Activity

SAMPLE Advertising Material Please ensure all elements are present in advertisement

Anytown General Hospital Presents:Title: “Continuing Nursing Education Program”

Target Audience:Goal:Objectives: (Minimum of 3)

Date: August 15, 2050

Time: 9:00am – 11:00am

Location: Anytown General Hospital Green Auditorium123 Main StreetAnytown, NY 12345

For registration information, please contact program coordinator Jane Smith at (123) 456-7890 or event url

Corporate Nursing Services-New York City Health and Hospitals Corporation is an approved provider of continuing education by New Jersey State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

This educational activity has been submitted to Corporate Nursing Services – New York City Health and Hospitals Corporation Continuing Nursing Education Provider Unit for award of ______ contact hours.

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FORM F: Co-Providership Agreement

New York City Health and Hospitals CorporationContinuing Nursing Education

This agreement is between: Provider [______________________________] and Co-Provider [_________________________________].

Agreement made as of the _____ day of _________ year of __________.

We are planning the activity: [___________________________________________].

Scheduled to be held on: [___________________________________________].

As the provider, [____________________________] will maintain overall responsibility for the following:

1.) Determination of the educational objectives and content,2.) Selection of the content specialist planners and activity presenters,3.) The awarding of contact hours, as appropriate, to the individual successfully completing the educational activity,4.) Recordkeeping procedures,5.) Evaluation methods and categories, and6.) Management of any commercial support or sponsorship.

Co-Provider, will assist in the planning of this activity. They will also be responsible for the following:

1.) 2.) 3.) 4.)5.)6.)

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Commercial support provided for this learning activity Yes No

Planners and presenters of this activity submitted a declaration of vested interests, or their lack of vested interests, as well as presenters’ discussion of off-label use. Yes No

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Signatures:

Approved Provider Unit Nurse Planner: ______________________________ Date: _________

Signature of Co-Provider:______________________________ Date: _________

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FORM G: SAMPLE SIGN-IN SHEET

Date: ________________ Time: _______________

Activity Title: ________________________________________________

Approval Number: ____________________________________________

Providing Agency: ____________________________________________

Name Email Nursing Identifier (LPN, RN, APN)

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New York City Health and Hospitals CorporationOffice of Patient Centered Care Corporate Chief Nurse Executive

346 Broadway, Suite 1136New York, NY 10013

Certificate of Completion

Participant: __________________________________________________________________________________________

has successfully completed ________ contact hours

on

Date: _________________________________________________________________________________________________

for continuing educational activity

Title: _________________________________________________________________________________________________

Corporate Nursing Services - New York City Health and Hospitals Corporation is an approved provider of continuing education by the New Jersey State Nurses Association, an Accredited Approver by the American Nurses Credentialing Center’s Commission on Accreditation.

This educational activity has been assigned provider code: XXXXXX-XXX-XX-___________