PHARMACEUTICAL SOCIETY OF IRELAND
Application Form for Training Providers of the Seasonal Influenza Vaccine Training Programmes (SIVTP)
For further information please contact the Professional Development and Learning unit at [email protected]
Disclaimer: While the PSI will strive to assure accurate, quality learning experiences through the educational programmes delivered in Ireland by accrediting formal courses of education, it cannot be expected to assume responsibility for any errors or other consequences arising from the use of information in a PSI--accredited programme. It will be the providers’ responsibility to ensure compliance with the Accreditation Standards required and the responsibility of the programme participants as professionals to interpret and apply the information they receive to their own practice as appropriate.
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Notice to Applicants:
Please refer to the accompanying Guidelines when completing the Application Form to help you demonstrate
compliance with the Standards. Please note that the Standards are set out in two parts:
Part 1 refers to general standards required for accredited training programmes for pharmacy.
Part 2 refers to additional standards specific to the seasonal influenza vaccine training programmes for
pharmacists and should be read in conjunction with Part 1.
All sections of the application form must be completed (Sections A, B and C).
If applying for accreditation of more than one training programme, please use a separate form for
each programme.
The Provider should provide a concise commentary in the application form that clearly sets out how each
standard has been met with due specific reference to the documentation that the Provider has provided. When
referring to programme documentation as evidence to support a standard, please identify the document
(including version nr.) in the far right hand column.
The application form should be signed by an Accountable Person responsible for quality.
Each application should be accompanied by 8 hard copies of the programme content and a link to the e-learning
component with access details for 8 assessors. A list of references and copies of templates should be provided
with the application e.g. evaluation forms, registration forms, conflict of interest forms and proposed certificate.
Part A: Applicant Details
The provider is required in this section of the application form to provide details of their organisation, the programme for
which accreditation is sought and to identify their experience and expertise
Provider’s Details:
Name of Provider:
Click here to enter text.
Address:
Click here to enter text.
Website Click here to enter text.
Contact Person for administration:
Tel: Click here to enter text. e-mail: Click here to enter text. website: Click here to enter text. Accountable Person Name: Click here to enter text. Tel: Click here to enter text. e-mail: Click here to enter text.
Status of the Provider: (e.g. university, commercial organisation, state agency etc..)
Click here to enter text. Please state the nature of your organisation’s business:
Click here to enter text.
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Programme Details:
Nature of Training Programme:
Please select the training programme which is the subject of this application :
Ab initio Refresher – Level 1 Refresher – Level 2 Anaphylaxis management including CPR
Target audience:
Please explain in terms of which pharmacists are most likely to benefit.
Availability of/Access to the Training Programme:
Successful completion of accredited training programmes related to immunisations and injections will be a requirement to
providing the immunisation service. All programmes therefore must be readily accessible to pharmacists in terms of timing
and location.
Where and when will the training be hosted, bearing in mind that training will be required on a national level
from mid-August.
For e-learning components, the Provider should describe where the module will be hosted, when it becomes live
and how participants can access it. User requirements should be outlined addressing the following: hardware;
internet access; operating systems software; settings; mobile devices.
Please state the likely duration that the participant will need to engage with the training programme across all
formats e.g. self-study, e-learning component, in order to achieve the learning objectives.
For e-learning components please provide a name and contact details for IT support and describe the support
service which will be made available
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Experience
Please use this section to summarise the provider’s experience in providing training to healthcare professionals, highlighting
in particular any experience in relation to immunisation and anaphylaxis management including CPR. Please highlight the
provider’s experience in the use of active, adult learning method and to demonstrate its experience in training for new
service delivery. Also please demonstrate the provider’s understanding of the pharmacy profession and the practice of
pharmacy in Ireland.
Accountability:
The Accountable Person will take overall responsibility for the quality of the programme and will be required to sign the
Declaration Form in Part C of the application to assure compliance with the standards. If the Accountable Person is not a
vaccinating pharmacist, then at least one vaccinating pharmacist must be nominated to be involved in the content and
delivery of all accredited activities.
The Accountable Person for this training programme is:
Name Contact details: Qualifications & Experience
Is the Accountable Person a vaccinating pharmacist? YES NO
If not, please nominate a vaccinating pharmacist (s) who will be involved in the development and delivery of the
training programme.
Name Contact details: Qualifications & Experience
Documentation
Please provide below a list of the documents submitted with this application, including a version number
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Part B – Programme Submission Form
Applicants are required to describe in this section of the application form how the training programme, addresses the PSI’s
standards relating to: (i) programme development; (ii) learning objectives and learning outcomes; (iii) programme content;
(iv) programme delivery; (v) assessment; (vi) programme evaluation and quality; (vii) resources; (viii) management and
governance. Please use the Specific Guidance in the Guidelines and consult the full text of the Standard when
providing your response to ensure full compliance, referring when necessary to programme documentation that
provides the evidence to demonstrate compliance.
Standard 1 - Programme Development
Standard Provider’s commentary and evidence Evidence
1.1 Training should have a strong emphasis on reflective learning and the programme
should have mechanisms to incorporate CPD elements such as: self-appraisal;
development of a personal learning plan; acting on the plan; recording of learning
activities; assessment of learning and reflection activities throughout
Provider’s commentary:
Evidence is required to demonstrate how the programme has incorporated reflection and other
CPD elements
e.g. self
assessment
form
1.2 The provider ensures that adult learning principles and active and/or interactive
learning activities are included in any self-directed and live programmes to assist
learners with the incorporation of knowledge and/or skills into their practice.
Provider’s commentary
What evidence can you provide to show that training will be consistent with this standard?
1.3 Providers and sponsors are encouraged to work with stakeholder organisations
(including but not limited to regulators, the HSE, pharmacy representative bodies, the
National Immunisation Office, schools of pharmacy, others in developing and
delivering the SIVTP .
Provider’s commentary
Evidence: list of stakeholders and a description of how they were involved in the development of
the module.
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1.4 Providers should assess the learning needs of the target audience – refer to full text of
Standard.
Provider’s commentary:
Evidence:
Standard 2 - Professional Learning Objectives/Outcomes
Part 1 – Generic Standards
2.1 Refer to Vaccine Specific Standard 2.1
2.2 Refer to vaccine Specific Standard 2.2
2.3 Programme providers and presenters should collaborate to identify the learning outcome
objectives prior to developing the programme content
Provider’s commentary:
Evidence:
2.4 Preferred learning format of the intended audience should be consistent to reflect adult
learning principles to ensure the most effective methods to achieve the outcomes are
employed
Provider’s commentary:
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Evidence:
Part 2 – Vaccine Specific Standards
2.1 Programmes must include written learning objectives that specify the learning outcomes
participants can expect to achieve upon successful completion of the programme.
Please also refer to Part 2 – Standard 2.4 at this point. To avoid duplication of information, please
use this section to provide the information requested therein. Use the reference column to indicate
where in the programme the learning objective is addressed.
Table 1: Learning Objectives and Learning Outcomes
Learning Objective Topic(s) Learning Outcome Reference
1
2
3
4
5
6
7
8
2.2 Learning outcomes should be stated as a measurable action or behaviour e.g. at the end of
the training programme the participant will have demonstrated good vaccination technique
to the satisfaction of the trainer
e.g. At the end of the training programme the pharmacist will …………..
Provider’s commentary:
Evidence:
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2.3 Learner assessment and overall programme evaluation should be related directly to stated
learning objectives
Comment:
2.4 Learning objectives of the overall programme should address the specific topics identified
in this standard.
Please use the table above to provide evidence that this standard has been achieved.
Provider’s commentary:
Evidence:
Learning Objectives of a “Live Training” programme should address the topics identified in
Appendix A of the Standards for ab initio training and the PSI requirements for 2013-2104
training for the refresher training:
Please use the table above to provide evidence that this standard has been achieved.
Provider’s commentary
Evidence:
e.g.
Table 1
Standard 3 - Programme Content
Part 1 – Generic Standards
3.1 You can refer to Part 2, Standard 3.1 to demonstrate compliance with this standard.
3.2 A programme involving multiple components, such as self-study and lecture segments,
should be integrally and logically sequenced to ensure a coordinated continuing professional
education experience.
Provider’s commentary:
A copy of the full programme format and schedule should be provided in an attachment as evidence.
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3.3 The provider must demonstrate how the programme content and materials have been
developed with access to appropriate internal and external expertise in the subject area.
Provider’s commentary:
Evidence: Please ensure that an accurate list of all people involved in developing the content is
provided. A Table is provided in Part B (Standard 7.1.3) for this purpose (Table 2).
Please provide the name of the vaccinating pharmacist(s) involved in the development of the training
programme?
3.4 Generic names of drugs must be used in the programme and all educational materials
wherever practicable; when use of a proprietary or brand name is required, ALL pertinent
proprietary names must be used where appropriate.
Have developers/presenters been made aware of this requirement? YES NO
Has all material been assessed to ensure compliance with this standard? YES NO
3.5 Keywords: active learning, adult learning, application of knowledge – refer to full text
You may cross refer to Standard 1.2 to avoid duplication of information.
Provider’s commentary:
Evidence:
3.6 Quality assurance
Refer to Guideline when completing the application form and also consider the following:
Who is responsible for maintaining training materials up to date?
What version control system is in place?
How does the Provider manage urgent changes required to content e.g. an urgent update in product
safety information?
Provider’s commentary:
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Evidence:
Part 2 – Vaccine Specific Standards
3.1 The SIVTP must allow registered pharmacists to:
build upon the theoretical and practical knowledge they already possess
acquire new theoretical knowledge related to the administration of drugs by injection
acquire competence in the psychomotor skills required to administer an
intramuscular injection
acquire additional theory and practical knowledge required to incorporate
immunisation practice into their own pharmacy practice model.
How will this be achieved?
Provider’s commentary:
Evidence:
3.2 The provider takes appropriate steps to assure the core content is related to current national
guidelines on injection and immunisation and/or other requirements approved by the PSI and
also related to contemporary pharmacy practice.
Provider’s commentary:
Evidence:
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3.3 Topic and content relevant to contemporary pharmacy practice are drawn on to support the
injection and immunisation learning programme through the inclusion of such topics as:
properties and actions of the vaccine(s); epidemiology of Influenza, characteristics, and
prevention; the pharmaceutical monitoring and management of patient therapy
Provider’s commentary:
Evidence:
3.4 The programme should be guided by the indicative desired programme content and
deliverables shown in Appendix A of the Interim Standards for ab initio training and the PSI
requirements for 2013-2104 training for the refresher training:
Provider’s commentary:
Evidence:
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Standard 4 – Programme Delivery and Learning Methods
Part 1 – Generic Standards
4.1 Instructional Methodology:
4.1.1 Refer to Part 2 Standard 4.1
4.1.2 Such programmes may be delivered in two parts to accommodate participants and
instructors, for example, a self-study learning component preceding a live, interactive
training session.
Read this standard in conjunction with Standard 4.1, Part 2.
Provider’s commentary:
Evidence:
4.1.3 Self-study programmes should include methodologies to reinforce and/or demonstrate that
the participants have met the learning objectives. Refer to full text.
Provider’s commentary:
Evidence: Please refer to the forms/documentation used to assess/reinforce learning in the right hand
column
4.1.4 Instructors in didactic and other delivery modes have the content knowledge and
instructional experience to support the independent learning process.
Please identify all instructors involved in didactic and other delivery modes and their level of
experience. Please use Table 2, Section B (Standard 7.1.3). Please provide CVs or a brief biography for
each instructor.
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Provider’s commentary:
Evidence:
4.1.5 Instructors in “live interactive” seminars will be experienced and comfortable with hands on,
experiential teaching and will have had previous experience in an instructional role.
Please identify all instructors involved in “live interactive” seminars and their level of experience.
Please use Table 2, Section B (Standard 7.1.3) Please provide CVs or a brief biography for each
instructor.
Provider’s commentary:
Evidence:
4.2 Principles of active, adult learning
4.2.1 The method of delivery should allow for , and encourage, active participation.
Provider’s commentary:
Evidence:
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4.2.2 The programme must take account of innovation and experimentation with different
delivery methods that incorporate principles of adult education and promote the application
and incorporation of knowledge into practice.
Provider’s commentary:
Evidence:
4.2.3 Proportion of participants to instructors in a live training programme is appropriate to
ensure optimal learning opportunities and hands-on experience.
Provider’s commentary:
Evidence:
Part 2 – Vaccine Specific Standards
4.1 Methodology for training for injections and immunisations include both theoretical and
practice components enabling pharmacists to demonstrate mastery of necessary skills.
Provider’s commentary:
Please refer to the relevant part of the training programme as evidence.
4.2 The live education seminar should reinforce and expand on the knowledge acquired in the
self-study component by providing pharmacists with the opportunities to address related
learning questions and concerns about provision of injections and immunisations and further
provide the opportunity to hands-on injection technique learning and practice.
Provider’s commentary:
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Evidence:
4.3 Programmes must be delivered by instructors with clinical and practical experience and
expertise in administering injections and providing vaccinations.
Provider’s commentary:
Evidence: Please identify all instructors and their experience in Table 2, Section B (Standard 7.1.3)
Please provide CVs or a brief biography for each instructor.
4.4 Live education seminar instructors and vaccinating pharmacist – refer to full text of the
standard.
Provider’s commentary:
Evidence: Please use Table 2, Section B (Standard 7.1.3) to provide the evidence required
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Standard 5 - Assessment of Learning
The programme must include a means of confirming participant engagement and achievement of learning objectives.
Assessment of participant learning will be required for both the on-line and face to face components of the training
programme.
Part 1 – Generic Standards
5.1 Assessment of participants should be directly related to the learning outcomes specified for the
programme. (You may cross refer to Standards 2.3,Part 1 to avoid duplication)
Provider’s commentary:
Evidence:
5.2 Describe the learner assessment tool/component that assesses the participants’ achievements in meeting
the learning objectives as per Guideline.
Provider’s commentary:
Evidence: Please provide copies of all assessment tools with reference to the learning outcome and use
the column on the right to refer to evidence for compliance with this standard
5.3 Learning assessment and integration of the vaccine service into practice. Refer to full text of
standard.
Provider’s commentary:
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Evidence:
Part 2 – Vaccine Specific Standards
5.1 Ideal assessment will be designed to go beyond simple recollection of facts and require the
participant to demonstrate that they have met the learning outcomes and are able to
incorporate that knowledge into a new pharmacy immunisation practice
Provider’s commentary:
Evidence:
5.2 Feedback to participants on all post-test performance, including provision of the correct
answers and rationale to the successful candidates, must occur in a timely manner
Provider’s commentary:
Evidence:
5.3 To demonstrate they have the required theoretical knowledge and practical skills to immunise
safely, some post-test is required. Participants must achieve a minimum score of 70% to
demonstrate the pharmacist has adequately met the learning objectives and outcomes of the
programme
Provider’s commentary:
Evidence: Please provide a copy of any post-test
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5.4 Participants who do not initially achieve a passing score on a post-test should be allowed one
more opportunity to re-do the test but should not have received formal feedback respecting the
correct answers and rationale. Appropriate feedback may be provided prior to the re-test, but
this must be done in a manner that does not compromise the integrity of the test. If feasible, a
supplemental examination should be arranged for participants who do not achieve a passing
score)
Provider’s commentary:
Evidence:
5.5 Can the Provider provide a Certificate for each participant after the training programme?
YES NO
What criteria will be required before a Certificate can be issued?
Does the provider agree to highlight to the PSI significant deficiencies should they arise and to
suggest additional learning needs to address these? YES NO
Standard 6 - Programme Evaluation & Quality
A copy of the Providers Evaluation Form must be provided.
6.1 Assessment of participants and programme evaluation must be directly related to the learning
outcomes specified for the programme. You can cross refer to Part 1, Standard 5.2 and/or Part
1, Standard 2.3
Provider’s commentary:
Evidence:
6.2 Every accredited programme must have a programme evaluation component. All participants
must have the opportunity to evaluate the quality of the programme
Provider’s commentary( Please include a comment on how participants will be given the opportunity
to complete a form):
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Evidence: Please attach copies of evaluation surveys that will be used.
6.3 Completed programme evaluation forms should be retained by the provider or sponsor for
audit purposes (copies of these may be requested by the PSIas part of the accreditation
process)
Provider’s commentary:
Evidence:
6.4 Key components to be addressed in the evaluation form – refer to full text of the Standard.
Provider’s commentary:
Evidence is required that the minimum requirements as specified in this standard are addressed.
Standard 7 - Expertise and Resources :
7.1. Programme Planners and Presenters:
7.1.1
7.1.2
Identify the programme planners with responsibility for developing the content of the training
programme.
Identify the presenters (speakers or facilitators of a programme) of the training programme with
evidence of their experience with clinical and practical subject matter expertise.
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7.1.3 Please use table below to provide evidence that persons with appropriate knowledge and practice
experience have participated in all stages of development, delivery and assessment of a programme.
You can use this form or attach a separate form with the application. This table should also be used to
identify personnel required in Part 1 – Standards 3.3, .4.1.4 and 4.1.5 and Part 2, Standards 4.2 and 4.3
Table 2: List of Personnel, Roles, Knowledge and Experience
Name Role Knowledge and Experience
Evidence
Development (Standard: Part 1 - 3.3, 7.1.3)
Delivery (Standards: Part 1 - 4.1.5 and 4.1.6 and 7.1.3. Part 2 – 4.3 and 4.4)
Assessment (Standard: Part 1 – 7.1.3)
7.1.4 Please describe the provider’s expertise in the subject matter of the programme.
Provider’s commentary:
Evidence:
7.1.5 Declaration of quality of content
Provider’s commentary:
Evidence: you can refer to the signed declaration form (Part C of this Application) here
Additional requirement:
Have all personnel involved in the planning, development, delivery and assessment of the
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training programme signed Conflict of Interest forms and have all relevant conflicts been
identified, and highlighted at the start of presentations? YES NO
(Note: you may be asked to provide evidence but it is not necessary at this stage to attach the signed
forms with the application, just the template)
7.2 Instructional Materials:
7.2.1 Standard: Instructional materials appropriate to the education and training may be
prepared and provided
Provider’s commentary:
Evidence:
7.2.2 Standard: All materials must be of satisfactory technical quality, consistent and current in
content.
Provider’s commentary on the quality system in place:
Evidence that the standard is met:
7.2.3 Standard: Materials must include a reference list
Please provide in an attachment a list of references relevant to each material.
7.2.4 Please provide here a bibliography for additional reading, if provided.
7.2.5 What copyright/intellectual property statement is included in the programme materials?
7.3 References:
7.3.1 List the references which will be available in the handout materials for all elements of the
programme.
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7.3.2 Describe the system for numbering and presenting references.
Does the same system apply to all instructional materials?
7.3.3 Can you confirm that each source has its own reference note? YES NO
Evidence:
7.3.4 Has material been checked to ensure that any unpublished observations or personal
comments are not cited? YES NO
Are developers/presenters/instructors aware of this standard? YES NO
7.3.5 Do all website references use the complete URL address and the date the website was
accessed?
YES NO
7.3.6 Please describe how sources are verified
7.3.7 Standard: References must be current, relevant and credible
Provider’s commentary:
Evidence:
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Standard 8 - Governance and Management
Sponsorship
8.1 Please declare any sponsors or third parties involved in the programme.
Is their involvement clear and explicit in the programme documentation?
YES NO
Evidence: please refer to relevant section of documentation
Governance
This section requires information on the governance mechanism rather than detailed information on management systems
per se. However it is useful to refer to evidence provided for standards 7.1.5, 7.2.2 and 7.3.6 and other relevant evidence to
support this standard
8.2 Governance system
Please describe the governance system in place in accordance with the Standard:
Evidence:
Additional Requirement: The Provider through the accountable person must provide
assurance in Part C (Declaration Form) that it is fully compliant with all legal, ethical,
regulatory, IT and financial requirements and that there are no issues that could affect the
smooth delivery of the training programme. Failure to provide an honest account in this
section will result in rejection of the application or revocation of accreditation.
Additional Requirement: Please provide details of the provider’s indemnity insurance cover
Advertising and Promotion
The PSI will reject any application that in its opinion, includes biased information or advertising of a product or company.
Where there is a valid evidence base for a specific therapy or agent, this may be stated, but must be referenced in a manner
that is appropriate for a scientific journal.
8.3 Promotion and Advertising – Conflicts of Interest and Role:
8.3.1 Is there any company/product advertising contained in the programme at any stage?
YES NO
If yes, please comment
8.3.2 Have all third parties been disclosed and acknowledged in the programme?
YES NO
Are relevant conflicts declared to participants YES NO
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Please identify conflicts which have been identified.
8.3.3 Have registration materials been checked for compliance with the specific requirements of
this standard? YES NO
Evidence: Please attach copies of registration forms
8.3.4 Describe what promotional material will be used, attaching any samples if available
8.3.5 Do you agree to comply with the PSI’s required statements relating to accreditation
including: notice that the programme has been approved by the PSI, the accreditation file
number and number of credits ( if relevant) assigned to the programme, date of initial
presentation and programme “expiry date” YES NO
8.3.6 Can you certify that the programme sponsors have not influenced the programme content?
YES NO
8.3.7 Is any and all financial support received from a programme sponsor/grant unrestricted?
YES NO
8.3.8 In relation to the sponsoring company and its products, please indicate in the right hand column
where in the programme they are referenced?
Can you confirm that they are NOT referenced other than in accordance with this
standard?
YES NO
8.3.9 Please identify any employees of programme sponsors and their roles in relation to the programme.
8.4 Privacy:
The Provider must provide assurance that they will respect participant privacy and confidentiality and will not use data for
other purposes without the consent of the participant.
8.4.1 Please confirm that all registration lists of registered participants will be handled in
compliance with applicable privacy laws? YES NO
Have all individuals involved with registration received the necessary training in relation
to applicable privacy laws? YES NO
How will programme participants be advised as to how, if at all, their registration information will
be used?
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8.4.2 Please confirm that registration lists will be used solely to confirm attendance at, or
participation in, a programme and that all personnel handling registration lists are aware
of this requirement.
YES NO
8.4.3 If you are including participants’ registration information in a ‘list of participant’s for distribution,
how will you obtain agreement from programme participants beforehand?
8.4.4 What personal information is required for registration and to obtain credit for successful completion
of the programme?
Does the provider provide assurance that programme participants who decline to provide
any personal information other than their name and registration number cannot be
penalised and are eligible for recognition of learning outcomes upon successful completion
of the programme, except where otherwise justified. YES NO
8.4.5 Describe what method will be used for reconciling those who registered against
those who actually participated in the programme and how the formal recognition of
satisfactory completion of the programme will be managed (e.g. through the issuance of
certificates).
Does the provider hereby provide assurance that it will fully comply with the PSI’s standards
relating to privacy? (Part 1 – 8.4.1-8.4.5) YES NO
Additional Requirement: Can the provider please confirm that any information provided
by the participant will only be used for the specific purposes of completing the training
programme. YES NO
Additional requirement: Please describe the mechanism in place to confirm that
pharmacists attending the training course are registered pharmacists and that they are
engaging in the correct course of training in line with PSI requirements for 2013/2014
training e.g. PSI registration number and a self-declaration by the pharmacists
accompanied by certificates of training completed in 2012/2013 or 2011/2012 as appropriate
Quality Assurance
The provider must describe the overall system of quality assurance which they have in place for
development, delivery and assessment of training programmes (addressing such things as learning
needs identification, instructional design, quality and consistency of content, verification of
references, training of personnel, consistency of change control, assessment, evaluation, risk
management, continuous improvement )
You should refer to evidence provided in other relevant sections (Part 1, Standard 3.6 and
Part 1, 7.2.2) to avoid duplication
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Provider’s Commentary:
Evidence:
Patient Safety
The provider should identify all potential risks to patient safety associated with the programme and
describe the measures taken to minimise risks and enhance patient safety.
Provider’s Commentary:
Evidence:
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C Part C: Declaration of Accountable Person
I have read the Standards and am fully aware of the PSI’s requirements for (insert name of training programme) in
relation to: programme development, content, delivery, learning objectives and outcomes, assessment,
evaluation and quality, resources, management and governance.
I acknowledge that the training programme, which is the subject of this application, is clinically relevant,
unbiased, complete, accurate, current and appropriately referenced, and can provide documentary evidence (e.g.
statements from planners/presenters) upon request to support this claim.
I confirm that:
all requirements in relation to references are met (Part 1 – Standards 7.3.1.-7.3.7) and references are
included in all handout materials for all elements of the programme (Part 1 – Standard 7.3.1).
appropriate governance is in place, both clinical and non-clinical, to assure that all trainers/lecturers are
formally trained and assessed as competent. (Part 1 – Standard 8.2).
robust governance and management systems are in place to ensure compliance with all ethical, legal,
regulatory, IT and financial requirements.
the quality system described in this application is fully operational.
all presenters have been advised of the requirement to declare any conflicts of interest .
all third parties are clearly acknowledged in the programme and all conflicts highlighted to participants.
an appropriate Risk Management exercise – focused on Patient Safety – has been undertaken and that
any learning from previous seasons’ training have been incorporated into the proposed training
programme for 2013-14. I further confirm that (insert name of provider) will continually monitor the
subject area during 2013-14 to identify potential risks to the quality of the programme and to patient
safety and that any updated training is provided to participants to address such risks.
all copies of completed evaluation forms will be provided to the PSI for audit purposes when requested
(Part 1 – Standard 6.3).
a report of the training programme will be provided to the PSI containing information requested as part
of the accreditation.
any references made to the PSI on programme materials (including promotional material ) will only be
in accordance with the PSI’s agreed accreditation statement.
all information provided and assurances given as part of this application are honest and accurate and
that (insert name of company) commits to being audited by the PSI as a condition of accreditation .
(insert name of company) consents to the PSI conducting its own evaluation of training among
participants
(insert name of company) consents to and will facilitate audits by the PSI of the training programme
Accountable Person: Name: _________________________________ Job Title: _______________________________
Signed:____________________________________________________________________________
Dated:____________________________________________________________________________ Encl: Application Form, copy of programme schedule and instructional materials (or access details for on-line modules); List of
references; Evaluation Form ; Assessment forms/documentation; Conflict of interest template ; Copies of proposed Certificate