CENTER FOR NURSING EXCELLENCE
APPLICATION FOR FACULTY DIRECTED CONTINUING EDUCATION ACTIVITY
Provider Unit Information
Primary Nurse Planner for BWH Nursing Provider Unit:
Deborah Farina Mulloy, PhD, RN, Associate Chief Nurse, Quality and Center for Nursing Excellence;
1620 Tremont Street, Boston, MA 02120: 617-732-4835; dmulloy1@partners.org
Alternate Primary Nurse Planner for BWH Nursing Provider Unit:
Linda A. Evans, PhD, RN, Nursing Program Director, Center for Nursing Excellence; 1620 Tremont Street,
Boston, MA 02120: 617-525-7789; levans3@partners.org
Please email Completed application to: nursingceurequest@partners.org.
Does the content of the educational activity enable the learner to acquire or improve knowledge or skills beyond
basic knowledge and enhance professional development or performance of the nurse?
Yes
No (if No, contact Primary Nurse Planner)
Is the content of the educational activity generalizable regardless of the employer?
Yes
No (if No, contact Primary Nurse Planner)
Has this educational activity been submitted for continuing education credits in disciplines other than nursing?
Yes
No
If yes, please describe:
Has this program been approved by another ANCC Provider?
Yes
No If yes, Please list:
CONTACT PERSON FOR THIS ACTIVITY:
Name & Credentials:
Address:
Daytime Phone including extension:
CE Application 2/15
Email Address:
Section #1 Demographic Information
Program #
(for CNE to designate)
Presentation location:
(BWH is accepted for all onsite programs)
Program Date (s):
Time of Program (ex 9:00-10:00 am):
Title of your Program:
Total # of Attendees:
Live Presentation
Yes
No
Packaged Program (enduring, video, online)
Yes
No
Contact Hours:
Contact hours are awarded to participants for those portions of the activity devoted to didactic or clinical experience and to the evaluation components of
the activity. One contact hour equals 60 minutes. Contact hours may be awarded in ½ hour increments. If rounding is desired, contact hours will be rounded
down.
Goal of your Program: What the learner will be able to do at the end of the learning activity?
Section #2 Planning Committee
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 two members: a Nurse Planner (BSN prepared or higher) and
one other planner (nurse or non-nurse)
 There are 3 roles on the planning committee: Nurse Planner, Target Audience Representative, Subject
Matter Expert. The Nurse Planner may also be the Subject Matter Expert.
 The Nurse Planner must be knowledgeable regarding CE process and is responsible for adherence to the
ANCC criteria.
 Each member of the planning committee must submit a Biographical/Conflict of Interest Form. Click here
for a Biographical Data Form.
Committee Member Name
Credentials
Degrees
Role on
Committee
Nurse Planner
Target Audience
Representative
Subject Matter
Expert
CE Application 2/15
Primary Nurse Planner who supported the planning committee of this activity:
Linda A. Evans, PhD, RN, Nursing Program Director, Center for Nursing Excellence; 1620 Tremont Street,
Boston, MA 02120: 617-525-7789; levans3@partners.org. Dr. Evans is current on criteria set forth by ANCC and the
Northeast Multi-State Division
Section #3 Faculty/Presenters/Authors
Faculty/Presenters/Authors must have 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. Faculty/Presenters/Authors do not have to be nurses, but nurses should address nursing
care and nursing implications, as applicable. Each faculty/presenter/author must submit a
Biographical/Conflict of Interest Form. Click here for a Biographical Data Form.
Faculty/Presenter/Author Name
Credentials
Degrees
Qualifications of Faculty/Presenters/Authors supported by: (Check all that apply).
Content expertise
Demonstrated comfort with teaching methodology (e.g., web-based, etc.)
Presentation skills
Familiarity with target audience
Other –Describe:
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:
CE Application 2/15
Section #4 Assessment of Learner Needs:
1. Identify the target audience:
All RNs
Advance Practice Nurses
Nurses in Specialty Areas (Identify Specialty):
LPNs
Inter-professional (Describe; for example MD, SW, PT, and OT):
Other - (Describe; for example unlicensed assistive personnel):
2. 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 opportunities
Reviewing evaluations of previous educational activities
Reviewing trends in literature, law and health care
Other - Describe:
3. Indicate source of supporting evidence for needs assessment data. (Check all that apply)
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
Section #5 Program Design
1. Gap Analysis: (Based on the needs assessment)
Gap in Knowledge (knows)
Gap in Skills (knows how)
Gap in Practice (shows/does)
Other - Describe:
2. Purpose: State the purpose in relation to the outcome desired of the learner at the conclusion of the activity.
This can be a restatement of your goal on page 2 and should be congruent with your desired learning outcome.
CE Application 2/15
3. Evidence Base of Content: (i.e. Current References, literature, web source, expert resource, organizational
expertise etc):
4.
Learner Feedback: Learners will be provided feedback via:
Question and answers during activity.
Self-check questions.
Engaging learners in dialogue.
Return results of testing.
Return demonstration
Role play
Other - Describe:
5.
Successful Completion of Education Activity:
A. Criteria for successful completion for live and enduring material/web-based activities include:
(Check all that apply)
Attendance at entire event or session
Completion/submission of evaluation form
Completion of a Pre and Post Test
Return demonstration
Other - Describe:
B . Rationale for method selected above to determine successful completion: (Check all that
apply)
Method of evaluation selected
Importance of content knowledge
Importance of content application
Required by employer or organization
Other - Describe:
C. Contact Hour Calculation: What was the method for calculating the contact hours? (Select one)
Pilot Study
Historical Data
CE Application 2/15
Complexity of content and data
Other - Describe: Request of target audience
5. Verify Participation
Attendance/participation will be verified through sign in sheets/registration form.
Signed attestation by participant verifying completion of entire or part of the activity.
Collection of participation electronic verification via HealthStream©.
No partial credit is awarded
Contact hours awarded based on # of sessions attended
Other - Describe:
Section #6 Evaluation
A.
B.
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)
Upon completion of the activity, a summative evaluation is generated and will be reviewed to
assess the activity's effectiveness by the Nurse Planner and to identify how results may be used to
guide future educational activities.
Section #7 Activity Approval Statement for Publicity Materials
All communications, marketing materials, certificates, and other documents that refer to awarding contact hours
or continuing education credit for an individual educational activity must include the following statement. The
statement must be displayed clearly to the learner and must be worded as written below. The
accreditation/approval statement must stand alone on its own line of text. When referring to contact hours, the
term "awarded” is used.
Brigham and Women’s Hospital is an Approved Provider of continuing nursing education by the
Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
Type of advertising used:
Flyer/brochure
Memo/Letter
Meeting Notice
E-mail
Web site
Social Media
Other - Describe
CE Application 2/15
Copy of advertising materials must be included in the activity file.
Section #7 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.
Commercial support or sponsorship will be received
Yes
No
If No, skip to Section #8 Disclosures
If Yes, complete items A, B, C, D and attach the signed agreement(s).
A. Commercial support/sponsorship will be provided by the following:
Name of Organization
Funding or In-Kind
Donation
Type of Organization
(commercial interest or
non-commercial interest)
B. Content integrity 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:
C. Bias will be prevented by: (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.
In addition to the above, the session will be monitored and violators of policy will not
be asked to present again.
Other - Describe:
D.
Signed commercial support or sponsor agreement attached.
CE Application 2/15
Section #8 Disclosures
Learners 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. In enduring materials (print,
electronic, or Web-based activities), disclosures must be visible to the learner prior to the start of the educational
content. 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.
Disclosures always required:
1. Successful Completion: Purpose and/or objectives and criteria for successful completion
Information on advertising material.
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)
Slide visible to all participants (Attach copy)
Other - Describe: (Attach copy)
2. Absence or Presence of Conflict of Interest for planners and faculty/presenters/authors/content reviewers
disclosed to learners by:
Information provided in advertising.
Slide visible to all participants (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: (Attached 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.
3. Commercial support:
Not applicable
Slide visible to all participants (Attach Copy)
Information provided in advertising.
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)
Slide visible to all participants
Other - Describe: (Attached copy)
4. Sponsorship:
Not applicable
Information provided in advertising.
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)
CE Application 2/15
Other - Describe: (Attached copy)
5. Non-endorsement of products discussed/displayed in conjunction with this activity:
NO Products are being displayed. (No statement needed.)
Information provided in advertising.
Information provided in handouts. (Attach copy)
Information provided in print at the start of the non-live activity (Attach copy)
Other - Describe: (Attach copy)
6. Expiration date for awarding enduring materials contact hours 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.
Section #9 Documentation of Completion
Learners 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/accreditation statement
Name of learner
Section #10 Record Keeping
Records filed and stored at The Center for Nursing Excellence
Activity file records must be maintained in a retrievable file (electronic or hard copy) accessible to authorized
personnel for 6 years.
Section #11 Joint Providership
This activity will not be Joint Provided with another institution or provider unit. (Go to Section #12)
This activity will be Joint Provided with another institution or provider unit:
A. Joint Provider(s):
B. If Joint-Provided the following is required:
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 must include:

Determination of educational objectives and content
CE Application 2/15
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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 the
agreement on behalf of the Approved Provider
Name and signature of the individual legally authorized to enter into contracts
on behalf of joint provider(s)
Date the agreement was signed
Section #12 Content Outline
(Name and Credentials) (Name and Credentials) (Name and Credentials)
Educational Planning Table/CONTENT ACTIVITY FORM—LIVE PRESENTATIONS
OBJECTIVES
CONTENT (Topics)
TIME
FRAME
PRESENTER
TEACHING
METHODS
List learner’s objectives in
behavioral terms. Use Bloomberg’s
Taxonomy for a Reference
Provide an outline of the content
for each objective. It must be
more than a restatement of the
objective.
Review
1. Mandatory
Announcements
State the time
frame for each
objective in
Minutes
List the Faculty for
each objective.
Please put credentials
Describe the teaching
methods, strategies,
materials & resources
for each objective
Beginning of Program Activities
1.
2.
3.
4.
5.
6.
7.
8.
9.
2. Disclosures
3. Learning Objectives
4. Criteria for successful
completion of program
(DO NOT
include this
cell in
calculation of
contact hours)
Review
Review
Review
Review
Review
End of Program Activities
Review
1. Evaluation process
2. Evaluation time frame
3. Evaluation
CE Application 2/15
(Include time
allotment in
this cell in
calculation of
contact hours)
Section #13 : Nurse Planner Signature
Name/credentials attesting to adherence of ANCC requirements:
Date:
Brigham and Women’s Hospital is an Approved Provider of continuing nursing education by the
Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
CE Application 2/15