PLANNING TEMPLATE FOR EDUCATIONAL ACTIVITIES
For any questions regarding this form please contact Kathleen Feldman at kfeldman@mednet.ucla.edu
To be completed by Course Coordinator: Sections A-I
A.
Course Coordinator Name and Contact Information:
Title of Educational Activity:
Activity Type/Date:
☐ Provider-directed, provider-paced: Live (in person or webinar)

Date of live activity:
☐ Provider-directed, learner-paced: Non-live/asynchronous webinars

Start date of offering:
 End date of offering:
☐ Hybrid activity

Date(s) of non-live/asynchronous materials (e.g. pre-work) available:

Date of live portion of activity:
Open to non-UCLA participants:
☐ Yes
☐ No
Will you be charging participants?
☐ Yes
☐ No
Anticipated type of Contact Hours offered (this will be confirmed by the Nurse Planner):
☐ ANCC
☐ BRN
☐ None (Stop: Do not fill out this form)
List the NRE Nurse Planner assigned to this activity:_____________________
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PLANNING TEMPLATE FOR EDUCATIONAL ACTIVITIES
B.
Needs assessment/gap analysis. Description of the professional practice gap (e.g. what is the current problem or opportunity for improvement and the desired change in practice.)
Describe the current state or practice:
Describe the desired state or practice:
Describe the identified gap in knowledge, skills or practice:
Identify the educational deficit that underlies the professional practice gap. (Select all that apply)
☐ Knowledge (Doesn’t know)
☐ Skill (Doesn’t know how)
☐ Practice (Not able to show or do in practice)
Methods used to identify the professional practice gap. (Select all 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
☐ Evaluation data from previous education activities
☐ Trends in literature, law and health care
☐ Direct observation
☐ Other - Describe:
Provide a brief summary of data gathered that validates the need for this activity. Explain the results of the method checked above (e.g. what did the survey results indicate?)
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PLANNING TEMPLATE FOR EDUCATIONAL ACTIVITIES
C.
Description of the target audience. (Select all that apply)
☐ All RNs
☐ Clinical Nurses
☐ CNS
☐ Educators
☐ Nurses in a specialty area ☐ Managers
☐ Advanced Practice RNs ☐ Inter-disciplinary
☐ CCP
☐ LVN
☐ Other - Describe:
D.
Learning outcome . The overall purpose/goal from participation in this activity. Refer back to the desired state (e.g. Learners will demonstrate knowledge of the principles of infection prevention).
Identify the short-term and long-term evaluation methods to show a change in knowledge, skills and/or practices of target audience.
Short-term evaluation: Long-term evaluation:
☐ Learner-reported intent to change ☐ Learner-reported change in practice knowledge, skill, or practice
☐ Active participation in learning activity ☐ Change in quality outcome measure
☐ Post-test ☐ Return on Investment (ROI)
☐ Return demonstration ☐ Observation of performance
☐ Case study analysis ☐ Other – Describe:
☐ Simulation/Role-play
☐ Other – Describe:
Course outcome measure(s). A quantitative statement as to how the learner outcome will be measured to demonstrate the gap has been addressed (e.g. Participants will score 80% or higher on a post-test;
Participants will actively participate throughout the activity).
E.
Mechanism to provide learner feedback. Description of how the learner will be provided feedback.
☐ Engage learners in dialogue
☐ Question and answer during activity
☐ Provide results of pre and or post tests
☐ Debriefing session
☐ Other - Describe:
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PLANNING TEMPLATE FOR EDUCATIONAL ACTIVITIES
F.
Criteria for successful completion of the educational activity. Criteria for awarding contact hours for live and non-live/asynchronous activities. (Select all that apply)
☒ Completion of an evaluation form
☐ Attendance for a specified period of time (e.g. 100% of activity or miss no more than 10 minutes of activity). Describe:
☐
0%
☐ Successful completion of a return demonstration
☐ Other - Describe:
Rationale for method selected above to determine successful completion. (Select all that apply)
☐ Attendance required for active learning
☐ Importance of content knowledge (e.g. rationale for post-test)
☐ Importance of content application (e.g. rationale for return demonstration)
☐ Required by employer or organization
☐ Other - Describe:
Verification of learner participation.
☐ Attendance/participation verified through sign-in sheets.
☐ Attestation statement signed by participant to verify completion the activity.
☐ Collection of participation verification via computer log
☐ Other - Describe:
G.
Evidence to support content. Describe the type of sources used to create the content for this educational activity. References should be within the past 5-7 years. (Select all that apply)
☐ Literature/peer reviewed journals
☐ Evidence-Based Practice or Clinical guidelines (ex. www.guidelines.gov
; UCLA
Policies/Procedures; Professional Organization standards)
☐ Content experts’ opinion (individual, organization, educational institution)
☐ Other - Describe:
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PLANNING TEMPLATE FOR EDUCATIONAL ACTIVITIES
H.
Content of activity : List the agenda topics/ learning objectives for the activity with a description of the content, time frame, presenter, and teaching methods. Include the reference list at the bottom of the table. Please use additional page if necessary.
1.
AGENDA
Topics/learning objectives.
CONTENT
Outline of the content to support each topic/objective. (Do not just restate the objective.)
TIME FRAME
Minutes dedicated to each topic/objective.
(Include evaluation time.)
PRESENTER
Educator for each topic/objective.
TEACHING METHODS
Describe the learner engagement strategies (e.g. lecture, case study, simulation.)
2.
3.
4.
5.
6.
References:
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PLANNING TEMPLATE FOR EDUCATIONAL ACTIVITIES
I.
For advertising purposes, provide a brief description and list course objectives. (Optional)
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