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Organization NameActivity Title

ACTIVITY TABLE OF CONTENTS

A.) APPLICATION

B.) ACTIVITY PLANNING COMMITTEE MEMBERS & PRESENTERS

C.) COI REVIEW-FOR PLANNERS& PRESENTERS

D.) AGENDA/SCHEDULE

E.) REQUIRED ACTIVITY DISCLOSURES

F.)CONTACT HOUR CALCULATION SHEET

G.) EDUCATIONAL PLANNING TABLE(S)

H.) EVIDENCE-BASED REFERENCES

I.) EVALUATION METHOD(S)

J.) METHOD USED TO VERIFY PARTICIPATION

K.) COMMERCIAL SUPPORT AGREEMENT (IF APPLICABLE)

PHARMOCOTHERAPEUTIC CONTACT HOUR INFORMATION (IF APPLICABLE) P1: INDIVIDUALS DISCUSSING PHARMOCOTHERAPEUTIC CONTENT & RELEVANT PHARM EXPERTISE………

P2: SESSIONS WITH PHARMOCOTHERAPEUTIC CONTENT………………………………………….

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P3: PHARMOCOTHERAPEUTIC CONTACT HOUR CALCULATION: ………………………………………

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Maryland Nurses AssociationIndividual Educational Activity

Applicant Eligibility Verification

Section 1: Eligibility

Submit this Eligibility Verification form with your application documentsApplicants interested in submitting an individual educational activity for approval must complete the Eligibility Verification and meet all Eligibility Requirements. Verification forms received from applicants that do not meet Eligibility Requirements will be rejected without substantive review.

Is this continuing education? Is this learning activity intended to build upon the educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to improve the health of the public and RNs’ pursuit of their professional career goals? ☐ Yes ☐ No If no, the activity is not eligible for approval.

______________________________________________________________________________Organization Name

______________________________________________________________________________Street Address

______________________________________________________________________________City State Zip/Postal Country

Identify Organization Type:

      Constituent Member Associations of ANA      College or University      Healthcare Facility      Health - Related Organization      Multidisciplinary Educational Group      Professional Nursing Education Group      Specialty Nursing Organization      Other: Describe -      

Is a currently licensed registered nurse with baccalaureate degree or higher in nursing is actively involved, as the nurse planner, in the planning, implementing and evaluation process of this continuing education activity?

     Yes      No

Please list the name and credentials of the nurse involved/responsible for this educational activity:

Nurse Planner's Name Credentials

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Section 2: Commercial Interest

The following section is intended to collect information about the applicant's corporate structure.

Below are some applicant types that are automatically exempt from ANCC’s definition of a commercial interest. If your type is listed below please identify with an “X”:

  Non-Profit 501(c)(3) organization  Blood banks  Diagnostic laboratories  Constituent Member Associations  National nurses organizations based outside the United States   Federal Nursing Services  Specialty Nursing Organizations

  A provider of clinical services directly to patients, including but not limited to hospitals, healthcare agencies and independent health care practitioners

  Acute care hospitals (for profit and not for profit)   Nursing homes (for profit and not for profit)   Rehabilitation centers (for profit and not for profit)   Group medical practices   Government organizations  Health insurance providers  Liability insurance providers

  Non-health care related companies whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on patients.

 An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to providers or developers of electronic health information systems, database systems, and quality improvement systems

  A single focused organization*devoted to offering continuing nursing education(exists for the single purpose of providing CNE)

 Other: Identify the applicant's exemption type if not listed above in section 2:

(* The single-focused organization exists for the single purpose of providing CNE)

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

     An "X" on this line identifies the applicant as exempt from ANCC’s definition of a commercial interest.

If you checked the box above, then you have completed this questionnaire, proceed to Section 5.

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Section 3 - Only complete this section if applicant organization is not exempt

     An "X" on this line identifies the applicant as not exempt from the ANCC AccreditationProgram’s definition of a commercial interest.

The following questions must be answered, so the Maryland Nurses Association can assess theapplicant's eligibility.

1. Does the applicant produce, market, re-sell, or distribute health care goods or services consumed by, or used on, patients?

Yes If YES, the applicant is not eligible for approval of Individual Educational Activities. No If NO, complete the next question

2. Is the applicant owned or controlled by a multi-focused organization (MFO*) that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients?

Yes If YES, complete the next question No If NO, this section of the questionnaire is complete, PROCEED TO SECTION 5.

3. Is the applicant a separate and distinct entity from the MFO*? Yes If YES, PROCEED TO SECTION 4 No If NO, the applicant is not a separate and distinct entity from the MFO* then the

applicant is not eligible for approval of Individual Education Activities.

Section 4: Commercial Interest Evaluation - Continued4. Does the multi-focused organization that owns the applicant have a 501-C Non-profit Status?

Yes No

5. If yes , does the company that owns the applicant advocate for a commercial interest (as defined by the ANCC Accreditation Program?)

Yes If YES, or not sure, please describe the relationship the company that the applicanthas with a commercial interest and the types of work the company that owns theapplicant does for or on behalf of a commercial interest that might be consideredadvocacy.

No If no, complete the next question

* Multi-Focused Organization (MFO) is an organization that exists for more than providing continuing nursing education.

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6. Is any component of the multi-focused organization an entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients?

Yes If yes, please describe the health care good or service consumed by or used on patients and the role of the entity in producing, marketing, re-selling or distributing those healthcare goods or services.

No If no, this section of the questionnaire is complete, proceed to Section 5.

If yes, please complete and submit the Individual Activity Eligibility Commercial Interest Addendum with this Form.

Section 5: Statement of Understanding

I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, compliance with all eligibility requirements and approval criteria throughout the entire approval period, and that the Maryland Nurses Association will be notified promptly if, for any reason compliance is not maintained while this application is pending or during any approval period. I understand that any misstatement of material fact submitted on, with or in furtherance of this application for activity approval shall be sufficient cause for the Maryland Nurses Association to deny, suspend or approval of this individual activity and to take other appropriate action.

(Eligibility Verification forms received without a signature incur a delay in processing which will cause a delay in the review of the individual education activity application.)

Name & Title Date

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Maryland Nurses AssociationIndividual Educational Activity Application

2017 Criteria

Date Form Completed:

ACTIVITY INFORMATION

Organization Name:

Activity Title:

Total number of contact hours being requested for approval:       (Indicate total of the number of contact hours for every session that will provide contact hours)

Maximum number of contact hours a participant can receive :     

Activity Type: ☐Provider-directed, provider-paced: Live (in person or webinar)

Date(s) of live activity:      

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

☐Blended activity (An activity that has both Enduring & Live formats, one of which is a pre-requisite for the

other and completion of both formats are required to receive a certificate for this activity)

Date(s) of enduring materials: Date of live portion of activity:

DEMOGRAPHIC DATA

Nurse Planner name and credentials:

Nurse Planner email address & Phone:

The Nurse Planner MUST: Be a RN who holds a current, unencumbered nursing license (or international equivalent). Have a Baccalaureate degree or higher in nursing (or international equivalent). Be actively involved in planning, implementing and evaluating this continuing education activity. Be knowledgeable of ANCC’s criteria and of adult learning principles.Important: If the Nurse Planner does not meet ALL OF THE ABOVE requirements, you must contact the MNA office before submitting this application.

Always download a new application from our website to ensure you have the current version and requirements. The ANCC application is frequently updated to reflect changes or updates to ANCC requirements and/or improve the application process.

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Contact Person for application status updates:

Contact Person email address & phone:

PAYMENT INFORMATIONIncluded with application Payment Method: Check Credit Card Payments are non-refundable once review has begun

EDUCATIONAL NEEDS ASSESSMENT

1. Description of the professional practice gap (e.g. change in practice, problem in practice, opportunity for improvement)

a. Describe the current state: (Identify the current knowledge skill or practice that requires improvement, review, updating or correction in the nursing profession or regarding patient outcomes)

b. Describe the desired state: (Describe the level of practice this activity is seeking to achieve or seeking to have nursing professionals work towards)

c. Identify the gaps: (Describe why nursing professionals lack the knowledge, skill or practice to perform at the improved level of practice outlined in this activity )

2. Evidence to validate the professional practice gap (check all methods/types of data that apply) ☐ Survey data from stakeholders, target audience members, subject matter experts or similar☐ Input from stakeholders such as learners, managers, or subject matter experts☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for

improvement☐ Evaluation data from previous education activities☐ Trends in literature, law and health care☐ Direct observation☐ Other—Describe:      

3. Provide a brief summary of data gathered that validates the need for this activity:

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(DO NOT PROVIDE A LIST OF REFERENCES) Provide a summary of the information obtained from the evidence checked above, which indicates there is a need for this activity.

4. Educational need that underlies the professional practice gap: (check all that apply)☐ Knowledge ☐ Skill ☐ Practice

5. Identify the target audience below. (You can identify more than one target audience)

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

7. Certificate of Successful Completion (select one)☐Will use the MNA certificate template for certificate for contact hours & submit a completed sample.☐Will create own certificate for contact hours with the required elements & submit a completed sample.

8. Marketing/Promotional Materials (select one)☐ This activity WILL NOT be marketed or advertised as awarding contact hours for nurses until it has

been approved. ☐ BEFORE APPROVAL to award contact hours, this activity WILL BE marketed as awarding contact

hours for nurses using the pre-approval statement.

Submit a copy of all versions of promotional materials for this activity referencing contact hours. ☐ (If applicable) PRE-approval promotional materials are included and labeled as PRE-APPROVAL ☐ POST-approval promotional materials included and labeled as POST-APPROVAL

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Sample list of verbs for used to form measureable learner outcomesTo create learner outcomes that provide specific behavioral indicators participants can achieve as a result of participating in an activity, this list identifies a sample list of verbs used to create learner outcomes that can be measured to determine the success of your activity.

NOT ACCEPTABLE in learner outcome statements: “Participants will be able to UNDERSTAND. …” Understand cannot be measured. Unacceptable.

Acceptable in learner outcomes are the following verbs listed belowThe Learner will be able to……………..Knowledge Application Synthesis Comprehension Analysis EvaluationDefine Interpret Compose Translate Distinguish AppraiseRepeat Apply Plan Restate Analyze EvaluateRecord Employ Propose Discuss Differentiate RateList Use Design Describe Calculate CompareRecall Demonstrate Formulate Recognize Experiment ValueName Dramatize Arrange Explain Test ReviseRelate Practice Assemble Express Compare ScoreUnderline Illustrate Collect Identify Contrast Select

Operate Construct Locate Criticize ChooseSchedule Create Report Diagram AssessShop Set up Review Inspect EstimateSketch Organize Tell Debate Measure

Manage Inventory JudgePrepare Question

RelateSolveExamineCategorize

Affective PsychomotorChoose Complete Assemble Design MendDescribe Differentiate Build Dismantle MixIdentify Explain Calibrate Fasten SketchLocate Justify Change Follow StartName Compare Clean Grip StirSelect Discriminate Compose Identify UseDiscuss Perform Connect Locate WeighPerform Synthesize Construct Make WrapPractice Use Correct ManipulatePresent Relate CreateSelect Combine

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9. Desired learning outcome(s) Using measureable verbs (see sample list above), identify the knowledge skills or practice will participants will be able to demonstrate or apply to practice after participating in this activity.

10. Criteria for Awarding Contact HoursCriteria for awarding contact hours for live and enduring material activities include: (check all that apply)

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

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

11. Outcome Measure(s): What methods of data collection or what data collection tool(s) will be used to determine if participants have accomplished the outcomes stated for this activity. Submit a copyExamples: (Evaluation, Post-Test, Quiz etc.)

12.Description of evaluation method: Describe how the evaluation method determines that participants have accomplished/met the outcomes stated for this activity. (Your evaluation must show evidence of participants ability to do as 1B above states, close the gap identified 1A & 4 above and that the behavior identified in 1A above has improved as a result of participating in this activity)

13. Short-term evaluation options:☐ Intent to change practice☐ Active participation in learning activity☐ Post-test☐ Return demonstration☐ Case study analysis☐ Role-play☐ Other – Describe:      

14. Long-term evaluation options:☐ Self-reported change in practice☐ Change in quality outcome measure☐ Return on Investment (ROI)

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☐ Observation of performance☐ Other – Describe:      

JOINT PROVIDER INFORMATION

15. Will this activity be Joint Provided? ☐ Yes ☐ No

If yes, identify the organization(s) joint providership of this activity has been arranged with: If activity will be jointly provided, make sure:

Where your organization’s name (Provider) and the Joint Providing organization’s name is shown, the Provider’s name is prominently listed in advertising.

Participants are made aware of the activity being jointly provided and the name of the joint provider is disclosed to participants prior to the start of the educational portion of the activity. Submit evidence

COMMERCIAL SUPPORT INFORMATION

16. Will this activity receiving Commercial Support from a Commercial Interest? ☐ Yes ☐ No

If yes, provide the following information:☐Commercial Support agreement between your organization and commercial interest attached.☐Provide Commercial Support information below.

Commercial Interest Type of Support Financial Amount of Support

If activity will receive commercial support, make sure: Participants are made aware of the activity is receiving commercial support and the commercial

interest name and type of commercial support is disclosed to participants prior to the start of the educational portion of the activity. Submit evidence

Note: Payments received from vendors/exhibitors as an exhibit fee to attend your activity, are not considered commercial support

BLENDED OR ENDURING ACTIVITY INFORMATION

Complete the following if this is a blended activity or an independent study whereby the learner completes learning independently, from a live presentation.

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17. Enduring Activity Plan/ProcessDescribe the elements of the independent study (an outline of all activities of the learner):

☐ Article(s): Title(s)       ☐ Audiotape: Title(s)       ☐ Videotape/DVD: Title(s)       ☐ On-line Program☐ Registration Form☐ Post-Test☐ Other – Describe:      

18. What method will participants use to receive assistance with resources or interact with the provider of the independent study/enduring portion of activity?

19. Contact Hour Calculation for enduring portion of activitya. What is the estimated time it should take for a participant to complete enduring this activity?

b. Identify method used to determine the time it will take to complete this enduring activity☐Pilot Study ☐Historical Data ☐Complexity of Content ☐ Other: Describe

c. Explain how the aforementioned method estimated the number of contact hours to be awarded

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Individuals in a Position to Control Content

Complete the table below for each person in a position to control content of the educational activity and include name, credentials, educational degree(s), role on the planning committee, and expertise that substantiates their role. Must have 2 RN’s on Planning Committee. There must be one Nurse Planner with a BSN or higher 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 (Content Expert).

Complete the table below for each person in a position to control activity contentThe individuals who fill the roles of Nurse Planner and Content Expert must be identified.

LIST PLANNERS AND PRESENTERSA B C D E

Name and credentials Role in activity Planning committee member? (Yes/No)

Conflict of interest disclosed? (Yes/No)

Related experience that deems individual qualified (for the activity role identified in Column B)

Example: Jane Smith, RN-MSN Nurse Planner Yes No MSN, trained & fully knowledgeable of ANCC’s criteria, remain up-to-date with ANCC criteria with current ANCC manuals, 12+ years planning CNE activities

Example: Sue Brown, RN, NCLEX-RN Content Expert Yes No NCLEX-RN, 6 years in LTC Nursing working with the elderly with debilitating injuries and illnesses. LTCNA Member

Example: John Doe, DNP Presenter No No LTC Nursing Director at County Clinic of Essex for 15 years planning, coordinating and managing care services

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ADDITIONAL IMPORTANT APPLICATION INFORMATION

FOR ACTIVITIES REQUESTING MORE THAN 3 CONTACT HOURSSubmitting Presenter BIOS/COIS, Evaluation forms and Planning Tables

For your presenter documentation, if your activity is requesting more than 3 contact hours, choose 3 hours of educational activity receiving contact hours from your activity, and the submit the Bio’s/Coi’s, Evaluation Forms and Educational Planning Tables for the presenters that fit in that 3 hours of activity for review with your application. Therefore if you have an activity requesting 30 contact hours for approval, you only need to choose 3 hours of presenter content to submit with your application for the reviewer to review your activity for approval. Although, the Bio’s/Coi’s, Evaluation Forms and Educational Planning Tables for the presenters in the remaining portions of the activity do not need to be submitted for approval, they must be kept with your educational activity file.   Please note this does not apply to the overall activity documents only the presenter documents.  The activity application, activity brochure, activity agenda and contact hour calculation sheet will need to reflect the entire activity from registration to closing.Therefore, if you submit an activity requesting 30 contact hours you would submit the activity brochure, activity agenda and contact hour calculation sheet showing the full 30 contact hours for reviewer to validate the amount of contact requested is accurate.

How to determine if a Conflict of Interest exists in your activity

Conflict of Interest occurs when:Individual has ability to control content of activity and has a financial relationship with a commercial interest and/or the products or services of the commercial interest are relevant to the topic of the educational activity

Commercial Interest is any entity producing marketing, reselling or distributing healthcare goods or services consumed by or used on patients. Could also be any entity owned or controlled by such an entity.

Note: Person or organization that is “making or selling” things that are consumed by or used on patients is considered a commercial interest. If you are “providing” patient care or services done in the course of taking care of patients is not a commercial interest

Examples of non-commercial entities:Hospitals, providers of clinical services, government entities, liability insurance providers, health insurance providers and diagnostic laboratories.

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Certificate of Successful Completion of

An Approved Continuing Nursing Education Activity

AWARDED TO:

First Middle Last

Successfully CompletedACTIVITY TITLE:

ACTIVITY CODE: CONTACT HOUR(S)

PRESENTATION DATE(s)

PRESENTATION LOCATION:

PROVIDER NAME:

PROVIDER ADDRESS: Street Address City State Zip

Provider’s Signature

This continuing nursing education activity was approved by the Maryland Nurses Association, an accredited approver by the

AMERICAN NURSES CREDENTIALING CENTER’S COMMISSION ON ACCREDITATION

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Activity Title:Activity Presentation Date(s):

ACTIVITY DISCLOSURES Participants must review this information prior to start of educational activity

1. ANCC Accreditation Statement The Maryland Nurses Association is an accredited approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

2. Criteria for Successful Completion In order to successfully complete this activity and receive full contact-hour credit for this CNE activity, you must:

3. Conflicts of Interest Was a conflict of interest or potential bias found for any activity planners and/or presenters of this educational activity?No Yes If yes, identify the individuals and the conflict of interest

4. Commercial Support Is this activity supported by an unrestricted or in-kind donation from a commercial interest?No Yes If yes, list the commercial interest organization(s) and the type of support received

5. Joint Provider Is this activity is activity jointly-provided?No Yes If yes, identify the joint providing organization(s)

6. Date Contact Hours for this activity will expire (for enduring activities only) Is this an enduring/learner-paced activity? No Yes

If yes, provide the expiration date/ last date learners will be able to access this activity to receive contact hours:

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Maryland Nurses AssociationProvider Responsibility Agreement

(Provider/Learner Paced)Providers must comply with the following policies and procedures. Failure to do so can jeopardize maintenance of approval of an activity and/or review of future continuing education applications.

1. MNA APPROVED ACTIVITY PUBLICITY: Once an activity is approved by MNA to award contact hours, the applicant may publish the following statement: “This continuing nursing education activity was approved by the Maryland Nurses Association an accredited approver by the American Nurses’ Credentialing Center’s Commission on Accreditation.”

2. CERTIFICATE OF SUCCESSFUL COMPLETION: The applicant is required to distribute a certificate of completion to each registered nurse who completes the Provider-paced or Learner-paced activity in its entirety and returns a completed evaluation form.

3. EVALUATION METHOD, SUMMARY & RECORDKEEPING: The applicant is required to provide participants with the evaluation method(s) reviewed and approved by MNA for their continuing educational provider-paced and learner-paced activities. If the evaluation method is requirement for successful completion of an activity, proof of completion must is required before certificates can be distributed to participants. Following the activity, the applicant is required to summarize all participant evaluations for each Provider-paced and Learner-paced activity and submit to MNA via mail with the participant sign in sheets. The applicant is required to retain the accessible summarized evaluations for (6) six years.

4. RECORDKEEPING SYSTEM: The applicant must retain full records of the educational activity for (6) six years after completion of the last session of the activity. This includes a completed application packet as approved, a list of all presentation dates with names and addresses of facilities where the activity was held, a copy of the attendance roster for each presentation date, and a copy of the summarized evaluations for each presentation date. These records should only be available to authorized individuals.

Reminder: Providers must provide a description of the particular recordkeeping they will maintain for the activity in the body of the application. Signature on the provider responsibility statement is not sufficient to meet this requirement.

5. QUALITY ASSURANCE: The MNA review mechanism includes an evaluation procedure which requires additional provider cooperation. For Learner Directed activities, the evaluation consists of direct mail evaluation of activity participants. The provider will be asked to submit to MNA a roster of nurses who completed the selected activity, with names and mailing addresses. No additional assistance is required of providers. The MNA will contact participants directly. Any educational activity may be selected for a site visit or online review. The selected provider is expected to permit the gratis attendance onsite or online of a peer reviewer from the MNA Continuing Education Approver Committee and to reimburse the MNA for mileage at the current US rate, to a maximum of 50 miles. Providers will be notified in advance if an educational activity has been selected for a site visit. Providers may request a postponement of a site visit by providing an appropriate justification in writing to MNA, but postponement is not guaranteed.

6. PROVIDER REPORTS TO MNAProviders need to summarize the evaluation data and send this summary with attendance rosters to MNA-CEAC within 30 days following the activity. For learner-paced or “enduring” presentations, this data may be submitted every 6 months during the approval process.

I have read the above policies and procedures and agree to comply:

Provider Signature Date