Application Form for Training Providers of Seasonal Influenza
Vaccination Training Programmes (SIVTP) 2014/15
For further information please contact Hugh Carroll at info@iiop.ie
Disclaimer: While the IIOP will strive to assure accurate, quality learning experiences through the
educational programmes delivered in Ireland by accrediting formal courses of education, it cannot be
expected to assume responsibility for any errors or other consequences arising from the use of
information in an IIOP--accredited programme. It will be the providers’ responsibility to ensure
compliance with the Accreditation Standards required and the responsibility of the programme
participants as professionals to interpret and apply the information they receive to their own practice
as appropriate.
Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Notice to Applicants:
Please refer to the accompanying Guidelines when completing the Application Form to help you demonstrate
compliance with the PSI’s Interim Standards for Accreditation of Vaccination Training Programmes for
Pharmacists (the Standards). Please note that the Standards are set out in two parts:
 Part 1 refers to general standards required for accredited training programmes for pharmacy.
 Part 2 refers to additional standards specific to the seasonal influenza vaccine training programmes for
pharmacists and should be read in conjunction with Part 1.
All sections of the application form must be completed (Sections A, B and C).
If applying for accreditation of more than one training programme, please use a separate form for
each programme.
The Provider should provide a concise commentary in the application form that clearly sets out how each
standard has been met with due specific reference to the documentation that the Provider has provided. When
referring to programme documentation as evidence to support a standard, please identify the document
(including version nr.) in the far right hand column.
The application form should be signed by an Accountable Person responsible for the quality of the programme
Each application should be accompanied by 6 hard copies of the course schedule, course content, supporting
documentation and a link to any e-learning component with access details for 6 assessors. A list of references
and copies of templates should be provided with the application e.g. evaluation forms, registration forms, conflict
of interest forms and proposed certificates. An electronic file containing all course material and supporting
documentation should also be provided. For Refresher-Level 2 training, copies of course materials are to be
made available on the IIOP’s learning platform in compliance with the IIOP’s IT requirements specified as part
of the tender.
Part A:
Applicant Details
The provider is required in this section of the application form to provide details of their organisation, the programme for
which accreditation is sought and to identify their experience and expertise
Provider’s Details:
Name of Provider:
Click here to enter text.
Address:
Click here to enter text.
Contact Person for administration’s name:
Tel: Click here to enter text.
e-mail: Click here to enter text.
Accountable Person Name: Click here to enter text.
Tel: Click here to enter text.
e-mail: Click here to enter text.
Website Click here to enter text.
Status of the Provider: (e.g. university, commercial organisation, state agency etc.)
Click here to enter text.
Please state the nature of your organisation’s business:
Click here to enter text.
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Programme Details:
Nature of Training Programme:
Please select the training programme which is the subject of this application :
Ab initio
Refresher – Level 1
Refresher – Level 2*
Anaphylaxis management including CPR
*Please note, Refresher – Level 2 training will be procured under tender and the successful tenderer will be
required to submit its material for accreditation.
Target audience:
Please explain in terms of which pharmacists are most likely to benefit.
Availability of/Access to the Training Programme:
Successful completion of accredited training programmes related to seasonal influenza vaccination will be a requirement to
providing this service. All programmes therefore must be readily accessible to pharmacists in terms of timing and location.
Where and when will the training be hosted, bearing in mind that training will be required on a national level
from mid-August.
For e-learning components, the Provider should describe where the module will be hosted, when it becomes live
and how participants can access it. User requirements should be outlined addressing the following: hardware;
internet access; operating systems software; settings; mobile devices.
Please state a breakdown of the likely duration that the participant will need to engage with the training
programme across all formats e.g. self-study, e-learning component, in order to achieve the learning objectives.
For e-learning components please provide a name and contact details for IT support and describe the support
service which will be made available to participants
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Experience
Please use this section to summarise the provider’s experience in providing training to healthcare professionals, highlighting
in particular any experience in relation to immunisation and anaphylaxis management including CPR. Please highlight the
provider’s experience in the use of active, adult learning method and to demonstrate its experience in training for new
service delivery. Also please demonstrate the provider’s understanding of the pharmacy profession and the practice of
pharmacy in Ireland.
Accountability:
The Accountable Person will take overall responsibility for the quality of the programme and will be required to sign the
Declaration Form in Part C of the application to assure compliance with the standards. If the Accountable Person is not a
vaccinating pharmacist, then at least one vaccinating pharmacist must be nominated to be involved in the content and
delivery of all accredited activities.
The Accountable Person for this training programme is:
Name
Contact details:
Qualifications & Experience
Is the Accountable Person a vaccinating pharmacist? YES
NO
If not, please nominate a vaccinating pharmacist (s) who will be involved in the development and delivery of the
training programme.
Name
Contact details:
Qualifications & Experience
Documentation
Please provide below a list of the documents submitted with this application, including a version number
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Part B – Programme Submission Form
Applicants are required to describe in this section of the application form how the training programme, addresses the PSI’s
standards relating to: (i) programme development; (ii) learning objectives and learning outcomes; (iii) programme content;
(iv) programme delivery; (v) assessment; (vi) programme evaluation and quality; (vii) resources; (viii) management and
governance. Please refer to the IIOP Guidelines for Training Providers of Seasonal Influenza Vaccination
Training Programmes 2014/15 and consult the full text of the PSI Interim Accreditation Standards when
providing your response to ensure full compliance, referring when necessary to programme documentation that
provides the evidence to demonstrate compliance.
Standard 1 - Programme Development
Standard
1.1
Provider’s commentary and evidence
Training should have a strong emphasis on reflective learning. The
Provider should demonstrate how the programme has incorporated
CPD elements such as: self-appraisal; development of a personal
learning plan; acting on the plan; recording of learning activities;
assessment of learning and reflection activities throughout
Provider’s commentary:
Evidence:
1.2
The Provider should describe how adult learning principles and
active and/or interactive learning activities are included in any selfdirected and live programmes to assist learners with the
incorporation of knowledge and/or skills into their practice.
Provider’s commentary:
Evidence:
1.3
Providers and sponsors are encouraged to work with stakeholder
organisations (including but not limited to regulators, the HSE,
pharmacy representative bodies, the National Immunisation Office,
schools of pharmacy, others) in developing and delivering the
SIVTP. A list of stakeholders and a description of how they were involved
in the development of the module should be provided
Provider’s commentary:
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Supporting Documentation
e.g. self-assessment form
Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Evidence:
1.4
Providers should describe the methods used to assess the learning
needs of the target audience – refer to full text of this Standard.
Provider’s commentary:
Evidence:
Standard 2 - Professional Learning Objectives/Outcomes
Part 1 – Generic Standards
Standard
Provider’s commentary and evidence
Supporting
Documentation
2.1
2.2
2.3
Dealt with in Influenza Vaccination Specific Standard 2.1
Dealt with in Influenza Vaccination Specific Standard 2.2
Describe how the Provider and presenters have collaborated to identify the
learning outcome objectives prior to developing the programme content.
Provider’s commentary:
Evidence:
2.4
Provide evidence that the most effective methods to achieve learning outcomes
appropriate to the target audience have been employed.
Provider’s commentary:
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Part 2 – Influenza Vaccination Specific Standards
2.1
Please identify the Learning Objectives for the programme that specify the learning
outcomes participants can expect to achieve upon successful completion of the
programme.
Provider’s commentary:
Evidence:
2.2
Please state the Learning Outcomes as a measurable action or behaviour. Example:
At the end of the training programme the participant will have demonstrated vaccination
technique to the satisfaction of the trainer.
Provider’s commentary:
Evidence:
2.3
Describe how learner assessment and overall programme evaluation is related
directly to stated learning objectives
Provider’s commentary:
Evidence:
2.4
Learning objectives of the overall programme should address the specific topics
identified in this Standard. Learning Objectives should address the topics
identified in Appendix A of the Standards for ab initio training and the PSI
requirements for 2014-2015 training for the refresher training:
Please use Table 1 below to provide evidence that this Standard has been achieved.
Table 1: Learning Objectives related to Topics
Learning Objectives
Topics
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Reference
Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Provider’s commentary
Standard 3 - Programme Content
Part 1 – Generic Standards
3.1
3.2
Dealt with in Influenza Vaccination Specific Standard 3.1
A programme involving multiple components, such as self-study and lecture segments,
should be integrally and logically sequenced to ensure a coordinated continuing professional
education experience.
A copy of the full programme format and schedule should be provided in an attachment as evidence.
Provider’s commentary:
Evidence:
3.3
The provider must demonstrate how the programme content and materials have been
developed with access to appropriate internal and external expertise in the subject area.
Please ensure that an accurate list of all people involved in developing the content is provided. A Table
is provided in Part B (Standard 7.1.3) for this purpose (Table 2).
Provider’s commentary:
Evidence:
3.4
Generic names of drugs must be used in the programme and all educational materials
wherever practicable; when use of a proprietary or brand name is required, ALL pertinent
proprietary names must be used where appropriate.
Have developers/presenters been made aware of this requirement? YES
Has all material been assessed to ensure compliance with this standard? YES
3.5
NO
NO
Please provide evidence that active or interactive learning activities employing adult learning
principles have been used to help participants incorporate the knowledge into their practice.
You may cross refer to Standard 1.2 to avoid duplication of information.
Provider’s commentary:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Evidence:
3.6
Quality assurance
Please describe the quality assurance system detailing how all education and training content
and materials are regularly reviewed, revised, and updated to reflect changes in best
practices, and pharmacy practice in general. Please also consider the following:
Who is responsible for maintaining training materials up to date?
What version control system is in place?
How does the Provider manage urgent changes required to content e.g. an urgent update in product
safety information?
Provider’s commentary:
Evidence:
Part 2 – Influenza Vaccination Specific Standards
3.1
The SIVTP must allow registered pharmacists to:

build upon the theoretical and practical knowledge they already possess

acquire new theoretical knowledge related to the administration of drugs by injection

acquire competence in the psychomotor skills required to administer an
intramuscular injection

acquire additional theory and practical knowledge required to incorporate
immunisation practice into their own pharmacy practice model.
How will this be achieved?
Provider’s commentary:
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
3.2
Describe what steps have been taken to assure the core content is related to current national
guidelines on injection and immunisation and/or other requirements approved by the PSI and
also related to contemporary pharmacy practice.
Provider’s commentary:
Evidence:
3.3
Describe how topic and content relevant to contemporary pharmacy practice has been drawn
on to support the injection and immunisation learning programme through the inclusion of
such topics as: properties and actions of the vaccine(s); epidemiology of Influenza,
characteristics, and prevention; the pharmaceutical monitoring and management of patient
therapy
Provider’s commentary:
Evidence:
3.4
The programme should be guided by the indicative desired programme content and
deliverables shown in Appendix A of the Interim Standards for ab initio training and the PSI
requirements for 2014-2015 training for the refresher training:
Provider’s commentary:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Evidence:
Standard 4 – Programme Delivery and Learning Methods
Part 1 – Generic Standards
4.1 Instructional Methodology:
4.1.1
4.1.2
Dealt with in Part 2 Standard 4.1
Identify and discuss those parts of the course which are delivered in two or more parts to
accommodate participants and faculty, for example, a self-study learning
component preceding a live, interactive training session.
Please read this standard in conjunction with Standard 4.1, Part 2.
Provider’s commentary:
Evidence:
4.1.3
Describe the methodologies used in self-study programmes to reinforce and/or demonstrate
that the participants have met the learning objectives.
Provider’s commentary:
Evidence: Please refer to the forms/documentation used to assess/reinforce learning in the right hand
column
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
4.1.4
Instructors in didactic and other delivery modes have the content knowledge and
instructional experience to support the independent learning process.
Please identify all instructors involved in didactic and other delivery modes and their level of
experience. Please use Table 2, Section B (Standard 7.1.3). Please provide CVs or a brief biography for
each instructor.
Provider’s commentary:
Evidence:
4.1.5
Instructors in “live interactive” seminars will be experienced and comfortable with hands on,
experiential teaching and will have had previous experience in an instructional role.
Please identify all instructors involved in “live interactive” seminars and their level of experience.
Please use Table 2, Section B (Standard 7.1.3) Please provide CVs or a brief biography for each
instructor.
Provider’s commentary:
Evidence:
4.2 Principles of active, adult learning
4.2.1 Describe how the method of delivery allows for, and encourages, active participation.
Provider’s commentary:
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
4.2.2
Describe how the programme takes account of innovation and experimentation with
different delivery methods that incorporate principles of adult education and promote the
application and incorporation of knowledge into practice.
Provider’s commentary:
Evidence:
4.2.3
Identify and justify the proportion of participants to instructors in a live training programme
to ensure optimal learning opportunities and hands-on experience.
Provider’s commentary:
Evidence:
Part 2 – Influenza Vaccination Specific Standards
4.1
Describe how the methodology for training for injections and immunisations includes both
theoretical and practice components enabling pharmacists to demonstrate mastery of
necessary skills.
Provider’s commentary:
Please refer to the relevant part of the training programme as evidence.
4.2
Describe how the live education seminar reinforces and expands on the knowledge acquired
in the self-study component by providing pharmacists with the opportunities to address
related learning questions and concerns about provision of injections and immunisations and
further provides the opportunity to hands-on injection technique learning and practice.
Provider’s commentary:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Evidence:
4.3
Programmes must be delivered by instructors with clinical and practical experience and
expertise in administering injections and providing vaccinations.
Provider’s commentary:
Evidence: Please identify all instructors and their experience in Table 2, Section B (Standard 7.1.3)
Please provide CVs or a brief biography for each instructor.
4.4
Identify the pharmacists involved in the programme, their roles and their level of experience
in administration of drugs via injection and provision of immunisations into their
own pharmacy practices. The Provider must also provide evidence that live
education seminar instructors are experienced and comfortable with ‘hands-on’ and
experiential training.
Provider’s commentary:
Evidence: Please use Table 2, Section B (Standard 7.1.3) to provide the evidence required
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Standard 5 - Assessment of Learning
The programme must include a means of confirming participant engagement and achievement of learning objectives.
Assessment of participant learning will be required for both the on-line and face to face components of the training
programme.
Part 1 – Generic Standards
5.1
Describe the procedure used to ensure that the assessment of participants is directly related to
the learning outcomes specified for the programme.
Provider’s commentary:
Evidence:
5.2
Identify what learning assessment methods will be used and discuss their use in assessing
achievement of learning objectives. Please demonstrate how the assessment modalities
employed [e.g. multiple choice questions, case-moderated study, objective structured
clinical examination (OSCE)] relate to the specific learning outcomes.
Provider’s commentary:
Evidence: Please provide copies of all assessment tools with reference to the learning outcome and use
the column on the right to refer to evidence for compliance with this Standard
5.3
Describe what forms of learning assessment are employed and refer to the relevant sections of
the programme where assessment takes place. Describe how training for new service
delivery by pharmacists will include assessment as to how the new service will be
integrated into practice.
Provider’s commentary:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Evidence:
Part 2 – Influenza Vaccination Specific Standards
5.1
Provide evidence that assessment will be outcomes-based rather than a simple recollection of
facts with the participant demonstrating their ability to incorporate newly acquired knowledge
into a new pharmacy immunisation practice.
Provider’s commentary:
Evidence:
5.2
Describe how feedback to participants on all post-test performance, including provision of the
correct answers and rationale to the successful candidates, will occur in a timely manner
Provider’s commentary:
Evidence:
5.3
Describe and refer to the post-test that will be used to demonstrate that participants have the
required theoretical knowledge and practical skills to immunise safely. Participants must
achieve a minimum score of 70% to demonstrate the pharmacist has adequately met the
learning objectives and outcomes of the programme.
Provider’s commentary:
Evidence: Please provide a copy of any post-test
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
5.4
Describe the process used for participants who do not initially achieve a passing score on a
post-test, including re-test and feedback.
Provider’s commentary:
Evidence:
Can the Provider provide a Certificate for each participant after the training programme?
YES
NO
What criteria will be required before a Certificate can be issued?
Does the provider agree to highlight to the IIOP significant deficiencies should they arise and
to suggest additional learning needs to address these? YES
NO
Standard 6 - Programme Evaluation & Quality
A copy of the Providers Evaluation Form must be provided.
6.1
Describe how assessment of participants and programme evaluation will be directly related to
the learning outcomes specified for the programme. You can cross refer to Part 1, Standard 5.2
and/or Part 1, Standard 2.3
Provider’s commentary:
Evidence:
6.2
Provide a copy of the evaluation survey used to evaluate participants’ satisfaction with the
programme.
Provider’s commentary:
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
6.3
Completed programme evaluation forms should be retained by the provider or sponsor for
audit purposes (copies of these may be requested by the IIOP as part of the accreditation
process). Describe the process for retention of completed programme evaluation forms.
Provider’s commentary:
Evidence:
6.4
Describe the key components respecting the quality of a programme which are addressed in
the evaluation form, and provide evidence that the minimum requirements as specified in this
Standard are addressed.
Provider’s commentary:
Evidence:
Standard 7 - Expertise and Resources:
7.1.
Programme Planners and Presenters:
7.1.1
Identify the programme planners with responsibility for developing the content of the training
programme.
7.1.2
Identify the presenters (speakers or facilitators of a programme) of the training programme with
evidence of their experience with clinical and practical subject matter expertise.
7.1.3
Please use table below to provide evidence that persons with appropriate knowledge and practice
experience have participated in all stages of development, delivery and assessment of a programme.
You can use this form or attach a separate form with the application. This table should also be used to
identify personnel required in Part 1 – Standards 3.3, .4.1.4 and 4.1.5 and Part 2, Standards 4.3and 4.4
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Table 2: List of Personnel, Roles, Knowledge and Experience
Role
Knowledge and Experience
Evidence
Development (Standard: Part 1 - 3.3, 7.1.3)
Name
Delivery (Standards: Part 1 - 4.1.4and 4.1.5 and 7.1.3. Part 2 – 4.3 and 4.4)
Assessment (Standard: Part 1 – 7.1.3)
7.1.4
Please describe the provider’s expertise in the subject matter of the programme.
Provider’s commentary:
Evidence:
7.1.5
Declaration of quality of content
Provider’s commentary:
Evidence: you can refer to the signed declaration form (Part C of this Application) here
Additional requirement:
Have all personnel involved in the planning, development, delivery and assessment of the
training programme signed Conflict of Interest forms and have all relevant conflicts been
identified, and highlighted at the start of presentations? YES
NO
(Note: you may be asked to provide evidence but it is not necessary at this stage to attach the signed
forms with the application, just the template)
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
7.2
7.2.1
Instructional Materials:
Provide evidence that instructional materials are appropriate to the education and
training
Provider’s commentary:
Evidence:
7.2.2
Describe the quality system in place to assure that all materials are of satisfactory technical
quality, consistent and current in content.
Provider’s commentary:
Evidence:
7.2.3
Materials must include a reference list
Please provide in an attachment a list of references relevant to each material.
7.2.4
Please provide here a bibliography for additional reading, if provided.
7.2.5
What copyright/intellectual property statement is included in the programme materials?
7.3 References:
7.3.1
List the references which will be available in the handout materials for all elements of the
programme.
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
7.3.2
Describe the system for numbering and presenting references.
Does the same system apply to all instructional materials?
7.3.3
Can you confirm that each source has its own reference note?
YES
NO
Evidence:
7.3.4
Has material been checked to ensure that any unpublished observations or personal
comments are not cited? YES
NO
Are developers/presenters/instructors aware of this standard? YES
NO
7.3.5
Do all website references use the complete URL address and the date the website was
accessed?
YES
NO
7.3.6
Please describe how sources are verified
7.3.7
Please provide assurance that references are current, relevant and credible
Provider’s commentary:
Evidence:
Standard 8 - Governance and Management
Sponsorship
8.1
Please declare any sponsors or third parties involved in the programme.
Is their involvement clear and explicit in the programme documentation?
YES
NO
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Governance
This section requires information on the governance mechanism rather than detailed information on management systems
per se. However it is useful to refer to evidence provided for standards 7.1.5, 7.2.2 and 7.3.6 and other relevant evidence to
support this standard
8.2
Governance system
Please describe the governance system in place in accordance with the Standard:
Evidence:
Additional Requirement: The Provider through the Accountable Person must provide
assurance in Part C (Declaration Form) that it is fully compliant with all legal, ethical,
regulatory, IT and financial requirements and that there are no issues that could affect the
smooth delivery of the training programme. Failure to provide an honest account in this
section will result in rejection of the application or revocation of accreditation.
Additional Requirement: Please provide details of the Provider’s indemnity insurance cover
Advertising and Promotion
The IIOP will reject any application that in its opinion, includes biased information or advertising of a product or company.
Where there is a valid evidence base for a specific therapy or agent, this may be stated, but must be referenced in a manner
that is appropriate for a scientific journal.
8.3 Promotion and Advertising – Conflicts of Interest and Role:
8.3.1 Is there any company/product advertising contained in the programme at any stage?
YES
NO
If yes, please comment
8.3.2
Have all third parties been disclosed and acknowledged in the programme?
YES
NO
Are relevant conflicts declared to participants YES
NO
Please identify conflicts which have been identified.
8.3.3
8.3.4
8.3.5
Have registration materials been checked for compliance with the specific requirements of
this standard? YES
NO
Evidence: Please attach copies of registration forms
Describe what promotional material will be used, attaching any samples if available
Do you agree to comply with the IIOP’s required statements relating to accreditation
including: notice that the programme has been approved by the PSI, the accreditation file
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
number and number of credits ( if relevant) assigned to the programme, date of initial
presentation and programme “expiry date” YES
NO
8.3.6
Can you certify that the programme sponsors have not influenced the programme content?
YES
NO
8.3.7
Is any and all financial support received from a programme sponsor/grant unrestricted?
YES
NO
8.3.8
In relation to the sponsoring company and its products, please indicate in the right hand
column where in the programme they are referenced?
Can you confirm that they are NOT referenced other than in accordance with this
standard?
YES
NO
8.3.9
Please identify any employees of programme sponsors and their roles in relation to the
programme.
8.4
Privacy:
The Provider must provide assurance that they will respect participant privacy and confidentiality and will not use data for
other purposes without the consent of the participant.
8.4.1
Please confirm that all registration lists of registered participants will be handled in
compliance with applicable privacy laws? YES
NO
Have all individuals involved with registration received the necessary training in relation
to applicable privacy laws? YES
NO
How will programme participants be advised as to how, if at all, their registration
information will be used?
8.4.2
Please confirm that registration lists will be used solely to confirm attendance at, or
participation in, a programme and that all personnel handling registration lists are aware
of this requirement.
YES
NO
8.4.3
If you are including participants’ registration information in a ‘list of participant’s for
distribution, how will you obtain agreement from programme participants beforehand?
8.4.4
What personal information is required for registration and to obtain credit for successful
completion of the programme?
Does the Provider provide assurance that programme participants who decline to provide
any personal information other than their name and registration number cannot be
penalised and are eligible for recognition of learning outcomes upon successful completion
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
of the programme, except where otherwise justified. YES
8.4.5
NO
Describe what method will be used for reconciling those who registered against
those who actually participated in the programme and how the formal recognition of
satisfactory completion of the programme will be managed (e.g. through the issuance of
certificates).
Does the provider hereby provide assurance that it will fully comply with the PSI’s
standards relating to privacy? (Part 1 – 8.4.1-8.4.5) YES
NO
Additional Requirement: Can the provider please confirm that any information provided
by the participant will only be used for the specific purposes of completing the training
course. YES
NO
Additional requirement: Please describe the mechanism in place to confirm that
pharmacists attending the training course are registered pharmacists and that they are
engaging in the correct course of training in line with PSI requirements for 2014/2015
training e.g. PSI registration number and a self-declaration by the pharmacists
accompanied by certificates of training completed in previous seasons as appropriate
Quality Assurance
The provider must describe the overall system of quality assurance which they have in
place for development, delivery and assessment of training programmes (addressing such
things as learning needs identification, instructional design, quality and consistency of
content, verification of references, training of personnel, consistency of change control,
assessment, evaluation, risk management, continuous improvement )
You should refer to evidence provided in other relevant sections (Part 1, Standard 3.6 and
Part 1, 7.2.2) to avoid duplication
Provider’s Commentary:
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
Patient Safety
Please identify all potential risks to patient safety associated with the programme and
describe the measures taken to minimise risks and enhance patient safety.
Provider’s Commentary:
Evidence:
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Application Form for Training Providers for Seasonal Influenza Vaccination Training 2014/15
C
Part C: Declaration of Accountable Person
I have read the Standards and am fully aware of the Standards for (insert name of training programme) in relation
to: programme development, content, delivery, learning objectives and outcomes, assessment, evaluation and
quality, resources, management and governance.
I acknowledge that the training course, which is the subject of this application, is clinically relevant, unbiased,
complete, accurate, current and appropriately referenced, and can provide documentary evidence (e.g.
statements from planners/presenters) upon request to support this claim.
I confirm that:

all requirements in relation to references are met (Part 1 – Standards 7.3.1.-7.3.7) and references are
included in all handout materials for all elements of the programme (Part 1 – Standard 7.3.1) for face to
face training.

appropriate governance is in place, both clinical and non-clinical, to assure that all trainers/lecturers are
formally trained and assessed as competent. (Part 1 – Standard 8.2).

robust governance and management systems are in place to ensure compliance with all ethical, legal,
regulatory, IT and financial requirements.

the quality system described in this application is fully operational.

all presenters have been advised of the requirement to declare any conflicts of interest.

all third parties are clearly acknowledged in the programme and all conflicts highlighted to participants.

an appropriate Risk Management exercise – focused on Patient Safety – has been undertaken and that
any learning from previous seasons’ training have been incorporated into the proposed training
programme for 2014-15. I further confirm that (insert name of provider) will continually monitor the
subject area during 2014-15 to identify potential risks to the quality of the programme and to patient
safety and that any updated training is provided to participants to address such risks.

all copies of completed evaluation forms will be provided to the IIOP for audit purposes when
requested (Part 1 – Standard 6.3).

any reports of the training programme containing information requested as part of the accreditation will
be provided to the IIOP in accordance with an agreed time schedule.

any references made to the IIOP or PSI on programme materials (including promotional material) will
only be in accordance with the IIOP/PSI’s agreed statement regarding accreditation or approval.

all information provided and assurances given as part of this application are honest and accurate and
that (insert name of company) commits to being audited by the IIOP as a condition of accreditation .

(insert name of company) consents to the IIOP conducting its own evaluation of training among
participants

(insert name of company) consents to and will facilitate audits by the IIOP of the training programme
Accountable Person: Name: _________________________________ Job Title: _______________________________
Signed:____________________________________________________________________________
Dated:____________________________________________________________________________
Encl: Application Form, copy of course schedule and instructional materials (or access details for on-line modules); List of
references; Evaluation Form ; Assessment forms/documentation; Conflict of interest template ; Copies of proposed Certificate
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