NYC Health + HospitalsPlanning Application for Nursing Educational

ActivitiesNote: Documentation is to be completed as part of the planning process, not

retrospectively.Demographic Data:

Title of Activity: Date Form Completed:

Total Number of Minutes of Educational ContentTotal Number of Contact Hours Requested

Activity Type: ☐ Provider-directed: Direct Sponsorship Live (in person or webinar)☐ Provider-directed: Joint Sponsorship Live (in person or webinar)

Date(s) & Time of Educational Activity:Location Date Time

Primary Nurse Planner Name Title Credential

s Email Contact Number

Has this educational activity been submitted for continuing education credits in disciplines other than nursing?

☐No ☐ Yes If yes, please choose all that apply:

Complete applications should be received at least 4 business weeks (20 days) prior to the date of the first presentation of the educational activity. Applications submitted less than 2 weeks (10 business days) may not complete the processing for the award of continuing educational credits. Applications submitted less than 1 week (5 business days) prior to the first presentation of the educational activity will not be reviewed and will require resubmission.

The Nurse Planner must be a currently licensed registered nurse with a baccalaureate degree or higher in nursing, and be actively involved in planning, implementing and evaluating this continuing education activity.

Physicians ☐Social Workers ☐Nursing Home Administrators ☐Other: ☐

This educational activity will be used to evaluate the Approved Provider’s impact on:☐ Nursing Professional Development – indicate outcome measure:

☐ Patient Outcome – indicate outcome measure: ☐ Other: ☐ None of the above

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Assessment of Learner Needs:

A. Identify the target audience: ☐ Registered Nurses ☐ Nurse Practitioners☐ LPNs ☐ Nurses in Specialty Areas Only (Identify Specialty):      ☐ Interprofessionals (Describe; for example MD, SW, PT, and OT): ☐ Other - (Describe; for example unlicensed assistive personnel):

B. Type of needs assessment method used to plan this activity? (Check all that apply)

☐ Surveying stakeholders, target audience members, subject matter experts or similar

☐ Requesting input from stakeholders such as learners, managers, or subject matter experts

☐ Reviewing quality studies and/or performance improvement a to identify opportunities for improvement

☐ Reviewing evaluations of previous educational activities☐ Reviewing trends in literature, law and health care ☐ Other - Describe:      

C. Indicate source of supporting evidence for needs assessment data. (Check all that apply. Approved Provider must be able to access this data upon request.)

☐ Annual employee survey☐ Literature Review☐ Outcome Data☐ 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.

(e.g., survey data, reference in literature, QI data, etc.)

D. Identify the appropriate gap for the intended target audience that this educational activity will address based on needs assessment data: Blooms taxonomy

☐ Gap in Remembering (knowledge)☐ Gap in Understanding (Competence)☐ Gap in Applying (Skill)☐ Other - Describe:      

E. Describe the process used to identify the gap(s) in knowledge/competence/skill/other:

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Qualified Planners and Faculty/Presenters/Authors/Content Reviewers:Please complete the table below for each person on the planning committee and include name, educational degree(s), credentials, and role on the planning committee. Planning committees must have a minimum of a Nurse Planner and one other planner to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered. The Nurse Planner and Content Expert must be identified.

A. Planning Committee

Educational Activity Planners Credentials/Degrees Role on Committee

Alfreda Weaver, MSNDirector, Healthcare Standards

MSN Nurse Planner

Select one.Select one.Select one.

Biographical/Conflict of Interest (COI) Form for each planning committee member is attached.

Yes ☐ No ☐

B. Identification, Evaluation and Resolution of Conflict of Interest for Planning Committee

1. Conflict of Interest evaluation for the Nurse Planner of this educational activity.a. Nurse Planner’s name: b. Does the Nurse Planner have a relationship with a commercial interest

organization that is relevant to the content of this educational activity:☐ Yes* ☐ No

* If yes, Nurse Planner must be recused from this educational activity or document resolution

c. Individual responsible for reviewing conflict of interest information for Nurse Planner (Nurse Planner may not evaluate his/her own conflict of interest information): Alfreda Weaver, MSN

2. The Nurse Planner is responsible for evaluating whether any planning committee member has a relationship with a commercial interest organization. For each planning committee member the Nurse Planner must document the following (document on each planner’s conflict of interest form):☐ No relevant relationship with a commercial interest exists. No resolution

required.☐ Relevant relationship with a commercial interest exists. The relevant

relationship with the commercial interest is evaluated by the Nurse Planner and determined not to be pertinent to the content of the educational

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activity. No resolution required. (Documentation should reflect rationale for content not pertinent).

☐ Relevant relationship with a commercial interest exists. The relevant relationship with the commercial interest is evaluated by the Nurse Planner and determined to be pertinent to the content of the educational activity. Resolution is required.

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3. In review of the biographical/COI forms, did the Nurse Planner and/or planning committee suspect that there might be COI and/or potential for bias for any planning committee members that were not self- reported on the form? ☐ Yes* ☐ No

If yes, what was the concern?       What was done to resolve it?      

4. Procedures used to resolve conflict of interest or potential bias, if applicable for this activity (document resolution process on each planner’s conflict of interest form as applicable): ☐ Not applicable since no conflict of interest.☐ 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 a 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 a 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.

5. Identify Content Reviewer if used as part of the resolution process on each planner’s conflict of interest form. Conflict of interest must also be evaluated for the Content Reviewer. Content Reviewer:

C. Faculty/Presenters/Authors

Faculty/Presenters/Authors must have documented qualifications that demonstrate their education and/or experience in the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. The qualifications must address how the individual is knowledgeable about the topic and how expertise has been gained. Faculty/Presenters/Authors do not have to be nurses, but nurses should address nursing care and nursing implications, as applicable. Biographical/COI Forms must contain information specific to this activity. If using the Educational Planning Table, Faculty/Presenters/Authors should be included.

Faculty/Presenter/Author Name Credentials/ Degrees

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Biographical/COI Form for each Faculty/Presenter/Author is attached. Yes ☐ No ☐

1. Describe how the needed qualifications of Faculty/Presenters/Authors are identified: (Check all that apply).

☐ Content expertise☐ Demonstrated comfort with teaching methodology (e.g., web-based, etc.)☐ Presentation skills☐ Familiarity with target audience☐ Other –Describe:      

2. Planning committee assures the qualifications of the Faculty/Presenters/Authors are appropriate and adequate by: (Check all that apply)☐ Review of resume/CV of faculty/presenter/author.☐ Recommendation by colleagues.☐ Review of literature written by faculty/presenter/author.☐ Observation of previous presentation by faculty/presenter/author.☐ New faculty/presenter/author being mentored by:      ☐ Other - Describe:      

D. Identification, evaluation and resolution of conflict of interest for Faculty/Presenters/Authors:

1. The Nurse Planner is responsible for evaluating whether any Faculty/Presenter/Author has a relationship with a commercial interest organization. For each Faculty/Presenter/Author, the Nurse Planner must document the following (document on each Faculty/Presenter/Author’s conflict of interest form):

☐ No relevant relationship with a commercial interest exists. No resolution required.

☐ Relevant relationship with a commercial interest exists. The relevant relationship with the commercial interest is evaluated by the Nurse Planner and determined not to be pertinent to the content of the educational activity. No resolution required. (Documentation should reflect rationale for content not pertinent).

☐ Relevant relationship with a commercial interest exists. The relevant relationship with the commercial interest is evaluated by the Nurse Planner and determined to be pertinent to the content of the educational activity. Resolution is required.

2. In reviewing the bio forms, did the Nurse Planner and/or planning committee suspect that there might be COI and/or potential for bias for any

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Faculty/Presenter/Author that was not self-reported on the form? ☐ Yes* ☐ No If yes, what was the concern?       What was done to resolve it?      

3. Procedures used to resolve conflict of interest or potential bias, if applicable for this activity (document resolution process on each Faculty/Presenter/Author’s conflict of interest form as applicable): ☐ Not applicable since no conflict of interest.☐ 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 a 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 a 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.

4. Identify Content Reviewer if used as part of the resolution process on each Faculty/Presenter/Author’s conflict of interest form. Conflict of interest must also be evaluated for the Content Reviewer:

Effective Design Principles

A. Identified Gaps: What is missing (List any gap in knowledge, skills and/or practice based on the needs assessment) that identifies the need for this activity?

☐ Gap in Knowledge (knowledge)☐ Gap in Skills (Performance)☐ Gap in Practice (Application) ☐ Other - Describe:      

B. Purpose: State purpose in relation to the outcome desired of the learner at the conclusion of the activity. Add here

C. Educational Objectives: Specific objectives for the learning activity are developed collaboratively by the planners and Faculty/Presenters/Authors (if applicable) and must relate to the purpose of the activity. Each objective should have one measureable action verb and should specify what the learner will know or do once the objective has been completed (the outcome of attaining the objective). Add here

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D. Quality of Content and Time FramesContent must: Be congruent with purpose and objectives Include details beyond a restatement of objectives Reflect the intent of the objectives Be numbered consistently with the related objective Be evidence-based or based on the best available evidence

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Content for this educational activity was chosen from:☐ Information available from the following organization/web site (organization

must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content; examples – Agency for Healthcare Research and Quality, Centers for Disease Control, National Institutes of Health):

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

☐ Clinical guidelines (example - www.guidelines.gov): ☐ Expert resource (individual, organization, educational institution) (book,

article, web site):

☐ Textbook reference: ☐ Other:

E. Learner Feedback: Check the best description or describe how learners will be provided feedback.

☐ Question and answers during activity☐ Self-check questions☐ Engaging learners in dialogue☐ Return results of testing☐ Return demonstration☐ Role play☐ Other - Describe:

F. Successful Completion: (Consistent with the purpose, objectives and teaching and learning strategies)1. Criteria for successful completion for live and enduring material/web-based

activities include: (Check all that apply) ☐ Attendance at entire event or session ☐ Attendance for at least % of event ☐ Attendance at 1 or more sessions ☐ Completion/submission of evaluation form ☐ Achieving passing score on post-test (Passing score is: %)☐ Return demonstration ☐ Other - Describe:      

2. Rationale for method selected above to determine successful completion: (Check all that apply)☐ Importance of content knowledge☐ Importance of content application ☐ Required by employer or organization ☐ Other - Describe:      

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Awarding Contact Hours

A. Verify Participation☐ Attendance/participation will be verified through sign in sheets/registration

form.☐ Signed attestation statement by participant verifying completion of entire or

part of the activity.☐ Collection of participation verification via computer log☐ Other - Describe:      

EvaluationA. Check or describe the methods of evaluation to be used: (Check all that apply)

☐ Evaluation Form ☐ Pre and/or Post-test (Attach a copy if testing is to be used)☐ Return Demonstration ☐ Case Study Analysis☐ Role Play☐ Longitudinal study with self-reported change in practice (long term method)☐ Data Collection related to quality outcome measure (long term method)☐ Observation of performance in practice (long term method)☐ Other - Describe:       (Attach a copy)

B. ☐ I agree upon completion of the activity a summative evaluation generated and submitted to CPE office.

C. ☐ The Nurse Planner and/or planning committee will review & submit the summative evaluation to assess the activity's effectiveness and to identify how results may be used to guide future educational activities.

Approval StatementThe NJSNA Approval Statement is an identifying feature of the approved provider unit and the educational activities they provide. The Approval Statement must be provided to the learner prior to the beginning of the educational program and on the certificates of completion.

A. Provide evidence of when the statement will be provided to learners

☐ 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):

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The approval statement must be displayed clearly to the learner and must be worded correctly according to the most current NJSNA CE Manual. The approval statement must stand alone on its own line of text. When referring to contact hours, the term accredited contact hours" should never be used. An organization is approved; contact hours are awarded.

B. Type of advertising to be used: ☐ Flyer☐ Brochure☐ Other – Describe: ☐ Copy of advertising materials must be included in the activity file.

Official Approved Provider statement:

Corporate Nursing Services-NYC Health + Hospitals 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.

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Commercial Support and Sponsorship A commercial interest is defined by ANCC as any entity either producing,

marketing, re-selling, or distributing health care goods or services consumed by, or used on , patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes 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.

Commercial Support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity.

A sponsor is identified as an organization that does not meet the definition of commercial interest. Sponsorship is financial, or in-kind, contributions given by an entity that is not a commercial interest, which is used to pay all or part of the costs of a CNE activity.If no commercial support or sponsorship received, select A and skip B – E. If commercial support or sponsorship is received, complete items B, C, D and E and attach the signed agreement(s).

A. ☐ This activity has no commercial support or sponsorship.B. Commercial support/sponsorship has been provided by the following:

Name of OrganizationFunding or In-Kind Donation

Type of Organization (commercial interest

or non-commercial

interest)

C. Content integrity has been/will be maintained by: (Check all that apply)☐ The commercial support/sponsorship policy/procedure has been discussed

with those providing commercial support or sponsorship.☐ The commercial support/sponsorship policy/procedure has been shared in

writing with those providing commercial support/sponsorship.☐ Faculty/Presenters/Authors have been informed of the policy/procedure re:

commercial support and sponsorship and agree to not promote the products or entity providing the financial or in-kind services.

☐ In conjunction with above, the session will be monitored and violators of policy will not be asked to present again.

☐ Other - Describe:      

D. The following precautions have been taken to prevent bias in the educational content: (Check all that apply).☐ Commercial support/sponsorship and bias has been discussed with each presenter.☐ Each Faculty/Presenter/Author has signed a statement that says s/he will

present information fairly and without bias.

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☐ In conjunction with the above, the session will be monitored and violators of policy will not be asked to present again.

☐ Other: Describe:

E. ☐ Signed commercial support or sponsor agreement attached. Statement that the provider of commercial support or sponsorship may

not participate in any component of the planning process of an educational activity, including:o Assessment of learning needso Determination of objectiveso Selection or development of contento Selection of presenters or facultyo Selection of teaching/learning strategieso Evaluation

Statement of understanding that the commercial support or sponsorship will be disclosed to the participants of the educational activity

Statement of understanding that the provider of commercial support or sponsorship must agree to abide by the provider’s policies/procedures

Amount of commercial support or sponsorship and description of in-kind donation

Name and signature of the individual who is legally authorized to enter into contracts on behalf of the provider of commercial support or sponsorship

Name and signature of the individual who is legally authorized to enter into contracts on behalf of the provider of the educational activity

Date the agreement was signed

Required Disclosures Provided to ParticipantsLearners must receive disclosure of required items prior to the start of an educational activity. In live activities, disclosures must be made to the learner prior to initiation of the educational content. Required disclosures may not occur or be located at the end of an educational activity. If a disclosure is provided verbally, an audience member must document both the type of disclosure and the inclusion of all required disclosure elements.

A. Required Disclosures 1. Successful Completion Disclosure: Purpose and/or objectives and criteria

for successful completion must be provided to learners prior to start of program. The method used: ☐ Information on advertising material (Attach copy)☐ Written information on handouts for activities/directions (Attach copy) ☐ Verbal statement and someone in the audience will witness and document

the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure)

☐ Other - Describe:       (Attach copy)2. Absence or Presence of Conflict of Interest for planners and

faculty/presenters/authors/content reviewers: (Check all that apply) 15

☐ Planners disclose no conflict of interest relative to this educational activity

☐ Faculty/Presenters/Authors/Content Reviewers disclose no conflict of interest relative to this educational activity

A. Absence of conflict of interest disclosed to learners by: ☐ Information provided in advertising (Attach copy),☐ Information provided on handouts. (Attach copy) ☐ Information provided in print at the start of the non-live activity

(Attach copy)☐ Verbal statement and someone in the audience will document the

verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure)

☐ Other - Describe:       (Attach copy) ☐ Planners disclose a conflict of interest relative to this educational

activity[List name(s):      ]

☐ Faculty/Presenters/Authors/Content Reviewers disclose a conflict of interest relative to this educational activity [List name(s):      ]

B. Presence of conflict of interest disclosed to learners by: ☐ Information provided in advertising.☐ Information provided on handouts. (Attach copy) ☐ Information provided in print at the start of the non-live activity

(Attach copy)☐ Verbal statement and someone in the audience will document the

verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure)

☐ Other - Describe:       (Attach copy)

B. Disclosures required, if applicable

1. Commercial support:

☐ Not applicable☐ Information provided in advertising (Attach copy)☐ Information provided in handouts. (Attach copy) ☐ Information provided in print at the start of the non-live activity (Attach

copy)☐ Verbal statement and someone in the audience will document the

verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure)

☐ Other - Describe:       (Attach copy)

2. Sponsorship:☐ Not applicable☐ Information provided in advertising (Attach copy)☐ Information provided in handouts. (Attach copy)

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☐ Information provided in print at the start of the non-live activity (Attach copy)

☐ Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure)

☐ Other - Describe:       (Attach copy)

3. Expiration date for awarding enduring materials contact hours:The expiration date must be visible to the learner prior to the start of the educational content. ☐ Not applicable - not enduring material☐ Learners notified how long contact hours will be awarded for the activity

on advertising.☐ Learners notified how long contact hours will be awarded for the activity

on directions page.

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Documentation of CompletionLearners receive documentation of successful completion of the educational activities.Document/certificate must include:

☐ Name and address of provider of the educational activity (Web address acceptable)

☐ Title and date of completion of educational activity☐ Number of contact hours awarded ☐ Official approval statement ☐ Name of learner

RecordkeepingA. Recordkeeping requirements for each activity file (Activity file records must be

maintained in a retrievable file (electronic or hard copy) accessible to authorized personnel for 6 years.)☐ 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:      

B. Records will be filed and stored at (list location): NYC Health + Hospitals, Office of Patient Centered Care, 125 Worth Street, Ste. 418, New York, NY 10013

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Co-ProvidershipIf activity will not be co-provided, select A and skip B;If activity will be co-provided, continue with B below and attach signed and dated agreement.

A. ☐ This activity will not be co-provided. B. Co-providership of this activity has been arranged with: List organization(s)

name(s):     The Approved Provider Unit's Nurse Planner must be on the Planning Committee and is responsible for ensuring adherence to the NJSNA Approval criteria, including the following: ☐ Name of Approved Provider is prominently displayed in all marketing material

and certificates☐ The name(s) of the organization(s) acting as the co-provider(s)☐ Statement of responsibility of the Approved Provider, which should include

the following: Determination of educational objectives and content Selecting planners, presenters, faculty, authors and/or content

reviewers Awarding of contact hours Recordkeeping procedures Developing evaluation methods and categories Management of commercial support or sponsorship

☐ Name and signature of the individual legally authorized to enter into contracts on behalf of the Approved Provider

☐ Name and signature of the individual legally authorized to enter into contracts on behalf of the co-provider(s)

☐ Date the agreement was signed

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.

Completed By: (Name and Credentials) Date

An “X” in the box below serves as the electronic signature of the individual completing this application and attests to the accuracy of the information given above.

☐ Electronic Signature (Required) Date

Submit electronic copy to: Alfreda.Weaver@nychhc.org and Olivia.Greene@nychhc.org Submit Hard copy to: 125 Worth Street Suite 418 Attn: Alfreda Weaver or Olivia Greene

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NYC Health + HospitalsEducational Planning Table

Title of Activity:

Total # of Contact Hours: AMA PRA Category 1 CreditsTM:

Learning Outcome(s): (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to…..

Select all that apply: ☐ Nursing Professional Development ☐ Social Work Professional Development ☐ Patient Outcome ☐ Physician Professional Development ☐ Other: Describe:

CONTENT (Topics)Provide an outline of the content

TIME FRAME PRESENTER/AUTHOR TEACHING METHODS/LEARNER ENGAGEMENT STRATEGIES

Example:I. Learner Objectives

A. Main Topic1. Content

Approximate time required for

content (minutes)

List First Name, Last Name List the learner engagement strategies to be used by Faculty, Presenters, Authors

Instructions: Use example above/below when completing this column. Note: A clear objective states what the learner will be able to do upon completion of the educational activity, in terms of behavioral change.  It identifies the desired outcome; whereas, the content for the activity is the information that supports achieving the objective, and not a restatement.

For every 60 minutes of content you must have a minimum of 1 - 2 objectives

Examples: LectureSlide PresentationRole PlayQ & A

I. Learner Objectives:

A. Main Topic:1. Content:

II. A.

1.III.

A. 1.

List the evidence-based references used for developing this educational activity (include year and author):

Total Minutes (on this planning table) divided by 60 minutes = contact hour(s)

Completed By: Name and Credentials Date

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NYC Health + Hospitals Form A: Biographical and Conflict of Interest Form

Title of Educational Activity:

Education Activity Date:

Role in Educational Activity: (Check all that apply) ☐ Planning Committee Member☐ Faculty/Presenter/Author☐ Content Reviewer☐ Other – Describe:      

Section 1: Demographic DataName 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: Expertise - Planning CommitteeIf a planning committee member, select area of expertise specific to the educational activity listed above:☐ Nurse Planner (responsible for ensuring adherence to NJSNA Approval/ANCC

Accreditation criteria)☐ Content Expert☐ OtherPlease describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, NJSNA may request additional documentation.)

Section 3: Expertise - Presenter/Faculty/Author/Content Reviewer☐ An "X" on this line identifies the expertise information the same as listed above.Please describe expertise and years of training specific to the educational activity listed above. (If the description of expertise does not provide adequate information, NJSNA may request additional documentation.)

Section 4: 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 Organizations are ineligible for approval or accreditation to provide continuing nursing education

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.

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

SalaryRoyaltyStockSpeakers BureauConsultantOther

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

Section 5: 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 a 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 a 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:     

Section 6: Statement of UnderstandingAn “X” in the box 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.

☐ Electronic Signature (Required) Date

Planner/Expert/Presenter/Faculty/Author/Content Reviewer Name and Credentials

Nurse Planner Signature (* If form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign).An “X” in the box below serves as the electronic signature of the Nurse Planner reviewing the content of this Biographical/Conflict of Interest Form. ☐ Electronic Signature (Required)

Alfreda Weaver, MSN Nurse Planner Name and Credentials Date

NYC Health + HospitalsJoint-Sponsorship Agreement

Note: Organizations requesting joint sponsorship may not provide or co-provide an educational activity.Title of Educational Activity:Activity Location (if live): Activity Date:Organization providing sponsorship:Approved Provider:Total amount of sponsorship: Area(s) of activity organization providing sponsorship would like to support:

☐ Unrestricted ☐Restricted*

☐ Speaker honoraria ☐ Meal☐ Speaker expenses ☐ Other (please list):

*The organization providing sponsorship may request that funds be used to support a specific part of an educational activity. The Approved Provider may choose to accept the restriction or not accept the sponsorship. The Approved Provider maintains responsibility for all decisions related to the activity as described below. Terms and Conditions1.

This activity is for educational purposes only and will not promote any proprietary interest of an organization providing sponsorship.

2.

The Approved Provider is responsible for all decisions related to the educational activity. The organization providing sponsorship may not participate in any component of the planning process of an educational activity, including: Assessment of learning needs Determination of objectives Selection or development of content Selection of planners, presenters, faculty, authors and/or content reviewers Selection of teaching/learning strategies Evaluation methods

3.

The Approved Provider will make all decisions regarding the disposition and disbursement of sponsorship in accordance with ANCC criteria.

4.

All sponsorship associated with this activity will be given with the full knowledge and consent of the Approved Provider. No other payments shall be given to any individuals involved with the supported educational activity.

5. Sponsorship will be disclosed to the participants of the educational activity. 6.

The organization providing sponsorship 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.

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 Sponsorship Agreement above.

Approved Provider Name:Address:

Name of Representative:Email Address:Phone Number:Fax Number:

☐ Electronic Signature (Required) Date: Completed By: (Name and Credentials)

Organization requesting sponsorship:Address:

Name of Representative:Email Address:Phone Number:Fax Number:☐ Electronic Signature (Required) Date: Completed By: (Name and Credentials)

NYC HEALTH + HOSPITALSCONTINUING PROFESSIONAL EDUCATION

Title of Activity: Activity Code:

Date: Location:

Circle the number that best describes your rating of each statement Poor Fair Good Excellent

1. Did the instructor relate the course objectives 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?

a) 1 2 3 4

b) 1 2 3 4

c) 1 2 3 4

3. Was the program relevant to your practice/discipline? 1 2 3 44. Were the training materials presented clearly, accurately and

helpful toward the learners understanding of the course? 1 2 3 4

5. Were the teaching strategies and tools appropriate? 1 2 3 46. 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 the number(1 = Poor, 2 = Fair, 3 = Good, 4 = Excellent)

Knowledge of Subject

Presentation orderly and

understandable

Debriefing discussion

engaging/organized

Small groups, role playing & assignments

a. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4b. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4c. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

8. Instructor(s) establish/maintain appropriate teaching strategies? 1 2 3 49. Overall assessment of this educational activity? 1 2 3 410. Was this program fair, balanced, and free of commercial bias? Yes No11. 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

The strengths of the program were:

What changes will you make in your clinical practice based on this learning activity?

How will you know in your work environment if this training was effective?

In 3 months’ time, what difference do you anticipate seeing in your work environment because of this training?

Additional Comments:

Check Appropriate Box(es):MD DO DDS PA NP RN LPN LMSW / LCSW PsyD Other

PARTICIPANT EVALUATION & ATTENDANCE ATTESTATION TYPE: CE HRS ☐ CME ☐ CEU ☐Email: _______________________________________ Name: ________________________________

CE hrs./CME/CEU credits or Certificate of Attendance is awarded upon completion of a legibly signed and submitted evaluation form.

NYC HEALTH + HOSPITALS

CONTINUING PROFESSIONAL EDUCATION

ACTIVITY EVALUATION SUMMARYTitle of Activity: Activity Code:

Date: Location:

Total # of Participants: ________ MD/DO: ________ RN/NP: ________ SW: ________ Other: ________Summarize participants rating of each statement Poor Fair Good Excellent1. Did the instructor relate the course objectives to the

overall goal & purpose of this learning activity? % % % %

2. To what extent were the following objectives of this learning activity achieved?a) % % % %b) % % % %c) % % % %

3. Was the program relevant to your practice/discipline? % % % %

4. Were the training materials presented clearly, accurately and helpful toward the learners understanding of the course?

% % % %

5. Were the teaching strategies and tools appropriate? % % % %6. The degree of confidence I have that I will use the

knowledge from this training? % % % %

7. Summarize participants rating of each presenterKnowledge of

SubjectPresentation orderly and

understandable

Debriefing discussion

engaging/organized

Small groups, role playing &

assignments(1 = Poor, 2 = Fair, 3 = Good, 4 = Excellent) 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

a. % % % % % % % % % % % % % % % %

b. % % % % % % % % % % % % % % % %

c. % % % % % % % % % % % % % % % %8. Instructor(s) establish/maintain appropriate

teaching strategies? % % % %

9. Overall assessment of this educational activity? % % % %10. Was this program fair, balanced, and free of

commercial bias? Yes % No %

11. 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 %

The strengths of the program were:

What changes will you make in your clinical practice based on this learning activity?:

How will you know in your work environment if this training was effective?:

In 3 months’ time, what difference do you anticipate seeing in your work environment because of this training?:

Additional Comments:

NYC HEALTH + HOSPITALS

Sign-In Sheet

PROGRAM:

DATE: TIME:

LOCATION:

Name/Credentials (NP, RN, CNM, CRNA, LPN etc.)

Email Signature

Nurse Planner / Program Director - Activity Review FormDate of activity: Activity Title: Lead Planner: Reviewer:

STRUCTURE REVIEW (facility design/location, parking, signage, temperature, seating, meals, bathrooms, AV support, etc): Note: Any answers of “N” need explanation

Facility was conducive to learning Y ☐ N ☐ Comments: Any issues identified? Recommend facility for future programs? Y ☐ N ☐ Comments:

PROCESS REVIEW (planning, implementation, program schedule, receipt/completion of required materials, etc):Note: Any answers of “N” need explanation

Planning process was efficient and effective Y ☐ N ☐Program implementation went as planned Y ☐ N ☐Marketing of program was effective Y ☐ N ☐Program schedule met needs of attendees Y ☐ N ☐Q&A time was sufficient for each session Y ☐ N ☐Comments: ______________________________________________________________

OUTCOMES REVIEWNote: Any answers of “N” need explanation

Summative Evaluation results (to be attached to this form)Attendance was as expected? Y ☐ N ☐Appropriateness/importance of topic relevancy validated (i.e. based on attendance, comments, evaluation summaries) Y ☐ N ☐Speaker feedback was positive Y ☐ N ☐Criteria for activity completion acknowledged? Y ☐ N ☐

Acknowledgment: Written☐ Verbal ☐

Comments:

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