UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
GUIDELINES:
Approvals may take up to 30 days, please plan accordingly. CPPN will not publish or take registration for a course until the
application has been approved. Submit completed application to cppn@ucdmc.ucdavis.edu
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APPROVAL PERIOD:
o C.E. applications are approved for a four-year period. To offer the same course after that date, the coordinator must submit a new C.E.
application.
TO COMPLETE THE APPLICATION:
O FIRST ASK YOURSELF SOME QUESTIONS:
 What is your target audience?
 What are the target audiences learning needs?
 What is the goal of the course?
 Learning experiences are expected to enhance the knowledge of the health care professional at a level above that required for
licensure.
ANCC Course Credit
o If you wish your course to be considered for ANCC credit you will need to meet the following criteria:
 Qualified Nurse Planner involved in planning of course from start. (Please contact Tish Campbell for a list of qualified Nurse
Planners.)
 Identified content expert involved in planning.
 Content must be beyond the basics of general nursing information.
 Cannot be a skills day or unit based class.
SIMULATION TRAINING in a CPPN Course utilizing the CENTER FOR VIRTUAL CARE (CVC)
o Must Be Coordinated Through CPPN
 Requires additional Education Design – for Simulation
COURSE CONTENT:
o The content of all continuing education courses must be relevant to the practice of registered nursing.
 Course content may include basic and advanced courses in the
 Physical, social and behavioral sciences, and advanced nursing in general or specialty areas
 Examples of acceptable courses include advanced nursing theory, pathophysiology, or application of content areas related to
specialized nursing; i.e. ACLS, chemotherapy, recent scientific knowledge, direct patient care such as; patient education strategies,
certification/re-certification skills, cultural aspects, or indirect patient care such as; nursing administration, publishing for professional
journals or books, current trends in nursing care, and legal aspects of nursing
 Examples of non-acceptable courses include CPR, equipment in-services, basic nursing skills or review of basic nursing care
procedures, orientation programs, courses for the lay public; i.e. parenting courses, self-awareness courses, courses geared to
personal financial gain, preparation of resumes, and job interviewing techniques.
COURSE REQUIREMENTS:
o Course offerings must be at least 60 minutes (1 hour) in length
 Credit cannot be offered for completing part of a course
Submit completed application to cppn@ucdmc.ucdavis.edu
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UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
GUIDELINES:
APPLICATIONS: For assistance/questions call or visit the Center for Professional Practice of Nursing office, 4900 Broadway, Suite #1630, (916)
734-9790. Approvals may take up to 30 days, please plan accordingly. CPPN will not publish or take registration for a course until the
application has been approved.
Title of Educational Activity: Should be specific to content. If course is part of a series of an ongoing program, precede specific class
title by series name; i.e., Pediatric Critical Care Program. The title should be less than 25 characters in length
Date(s) and Time of Course: Planned date(s) and time(s)
Target audience: Who is the class for
Skill Level: Refers to the level of course material being presented to target audience
Application submitted by: Completed by the coordinator of the class
Goal for overall course: Stated purpose or course description and expectation
Educational Design including: Objectives, Content, Time Frame, Presenters, Teaching Strategies
Biographical Conflict of Interest Form: Required for each speaker/presenter and member of the planning committee, application will
not be approved until received
Simulation Content: If CPPN course is to involve Center for Virtual Care please contact Karrin Dunbar
Expected Outcomes for course
Course Description: For printed and web advertisement
REGISTRATION: Participant pre-registration is recommended especially for space limited classes.
FUNDING: Non-employees must pay a fee of $15 per contact hour. If food is to be provided must state in information given to
CPPN and funding source.
Submit completed application to cppn@ucdmc.ucdavis.edu
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UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
California Board of Registered Nursing Provider No. CEP26
California Board of Behavioral Sciences Provider No. PCE737
Title of Course:
Date(s) of Course:
Course Start and
End Times:
Location:
Maximum # participants for course:
Target Audience:
Skill Level of Target Audience* Beginner (0-2 years experience)
experience) Advanced (> 5 years experience)
Submitted By:
Proficient (>2 - <5 years
Courses are approved for four years and may be
re-offered at any time during that period.
Records are maintained for four years after the
date of the last offering.
Title:
Department:
Telephone:
Interoffice Address:
CPPN Nurse Planner:
or
CPPN Course Coordinator:
Planning Group:
All persons in a position to control the content of the educational activity are required to complete the
Biographical and Conflict of Interest Form, 2013 Criteria – Available from CPPN
FOR CPPN OFFICE USE ONLY
Application reviewed and meets BRN regulatory criteria.
Application reviewed and meets BBS provider criteria:
BRN:
BBS:
Center for Professional Practice of Nursing
Center for Professional Practice of Nursing
ANCC:
Nurse Planner
Simulation Coordinator
Nurse Planner – Karrin Dunbar, RN
Center for Professional Practice of Nursing Program (open to all,
including community)
Date received:
Approval date:
Renewal date:
Cont Education hours:
Course number:
.
Unit Based Program (intended for individual units or nurses)
Submit completed application to cppn@ucdmc.ucdavis.edu
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UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
EDUCATIONAL DESIGN I DOCUMENTATION FORM
Title of Course:
Goal/Purpose of Course:
Objectives
Content (Topics)
List the educational objectives
Behavior/performance objectives are stated in
terms of what the student or learner will do,
rather than what the instructor will do.
Provide a short outline of the
content/topic presented and indicate
to which objective(s) the
content/topic is related.
Time
Frame
Presenter
Teaching Strategies
List the presenter for each
topic/content area.
Name, Credentials, Degrees
List the teaching strategies
by each presenter for each
topic or content area.
Insert additional row for each topic/session.
1. Discuss reasons for Mock Code Training.
Discussion about previous mock
15 min
code set up, difficulties encountered, (8problem solving, brain storming
8:15am)
Tish Campbell, RN, BSN
Lecture, PowerPoint
1. Discuss adult learning strategies and how
to apply them to Mock Codes
2. Discuss positive reinforcement and
corrective actions.
3. Discuss how to debrief after a session.
Teaching Strategies
Lecture
Practical Stations
Available Support, References and
Resources (Rapid Response Team)
Debriefing with all participants or
how to give constructive feedback
Tish Campbell, RN, BSN
Lecture, PowerPoint,
Group Activity
75 mins
(8:15 –
9:30am)
1.
1.
Submit completed application to cppn@ucdmc.ucdavis.edu
Document1
UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
EDUCATIONAL DESIGN I DOCUMENTATION FORM
Title of Course:
Goal/Purpose of Course:
Objectives
Content (Topics)
List the educational objectives
Behavior/performance objectives are stated in
terms of what the student or learner will do,
rather than what the instructor will do.
Provide a short outline of the
content/topic presented and indicate
to which objective(s) the
content/topic is related.
Time
Frame
Presenter
List the presenter for each
topic/content area.
Name, Credentials, Degrees
Insert additional row for each topic/session.
1.
1.
1.
Submit completed application to cppn@ucdmc.ucdavis.edu
Document1
Teaching Strategies
List the teaching strategies
by each presenter for each
topic or content area.
UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
MUST COMPLETE ONLY IF COURSE IS GOING TO INCLUDE SIMULATION
Yes
No
Do you have any previous experience with simulation?
Setting for Class:
Adult ED
L&D
Adult Med/Surg
Adult ICU Specialty:
NICU
PACU
Post Partum
Telemetry
Clinic Specialty_________
OR
CCTT
Pediatric ED
Pediatric ICU
Pediatrics
Other:
Title of Class:
Overall Scenario Topic:
Overall Scenario Goal:
Case Summary
For each scenario provide a short
version of what the scenario will
cover, providing only the main points.
Insert additional row for each case.
National Patient
Safety Standards
Nursing Quality
Indicators
Select, from the list below,
which standard will be
addressed in each
scenario
Select, from the list
below, which standard
will be addressed in
each scenario
Concept
Identified problems across
disease category and
populations.
* See list below
Critical Performance
Elements
List the performance criteria
necessary to Identify in the
scenario participants.
FOR ALL SIMULATION BASED
EDUCATION HAND WASHING
MUST BE INCLUDED
Hand Washing
Hand Washing
Submit completed application to cppn@ucdmc.ucdavis.edu
Document1
UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
Case Summary
For each scenario provide a short
version of what the scenario will
cover, providing only the main points.
Insert additional row for each case.
National Patient
Safety Standards
Nursing Quality
Indicators
Select, from the list below,
which standard will be
addressed in each
scenario
Select, from the list
below, which standard
will be addressed in
each scenario
Concept
Identified problems across
disease category and
populations.
* See list below
Critical Performance
Elements
List the performance criteria
necessary to Identify in the
scenario participants.
FOR ALL SIMULATION BASED
EDUCATION HAND WASHING
MUST BE INCLUDED
Hand Washing
Hand Washing
Hand Washing
Hand Washing
Submit completed application to cppn@ucdmc.ucdavis.edu
Document1
UC Davis Health System Center for Professional Practice of Nursing
APPLICATION FOR CONTINUING EDUCATION COURSE APPROVAL
National Patient Safety Standards
Nursing Quality Indicators
1. Improve the accuracy of patient identification
1. Nosocomial Infections
2. Improve the effectiveness of communication among care givers
2. Falls
3. Improve the safety of using medications
3. Pressure Ulcers
4. Reduce the risk of health care associated infections
4. Pain assessment, intervention and reassessment
5. Patient safety risk
Concept based approach to simulation education Creates an understanding or a relationship among conditions that
impact the situation and fosters systematic observations about a problem. Select one concept that applies to the topic
of the scenario.
1. Acid-base balance
8. Diversity
15. Infection
22. Perfusion
29. Thermoregulation
2. Addiction behavior
9. Elimination
16. Inflammation
23. Reproduction
30.Tissue Integrity
3. Cellular regulation
10. Family
17. Intracranial Regulation
24. Self
31. Violence
4. Cognition
11. Fluids & Electrolytes
18. Metabolism
25. Sensory Perception
5. Comfort
12. Grief & loss
19. Mobility
26. Sexuality
6. Culture
13. Health, wellness, illness
20.Mood & affect
27. Spirituality
7. Development
14.Immunity
21. Oxygenation
28. Stress & coping
Submit completed application to cppn@ucdmc.ucdavis.edu
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