The University of Mississippi Medical Center (UMMC)
School of Nursing
CE Planning Form/RSS Worksheet
Directions:
Thank you for your interest in providing quality continuing nursing education (CNE) for the nurses at UMMC. Eligibility for
becoming a nurse planner requires that you are an employee of UMMC, a registered nurse with a bachelor of science in nursing
degree, or higher, have education and/or experience in the area of the CNE activity, and participate in planning meetings with the
Primary/Lead Nurse Planner, Dr. Renée Williams, RN. Continuing education assists the learner in acquiring new knowledge
and skills to enable advanced decision making in providing quality healthcare, enhancing professional attitudes, advancing
career goals and promoting professional development.
There are two types of CNE activities that can be planned: Education Design I/Provider Directed and Education Design
II/Learner Directed. Please contact the SON Continuing Education Office if you are interested in learning more about planning
CE activities.
Planning process for CNE at UMMC:
1. Contact the SON Continuing Education Office at 601-984-6227 to schedule planning meetings with the Primary/Lead
Nurse Planner, Dr. Renée Williams, RN, Director of Continuing Education, (DCE)
2. When meeting with the Primary/Lead Nurse Planner, bring a completed typed copy of the attached 2 page planning form
worksheet with Attachments A & B forms. A computerized version of the planning form is available from the School of
Nursing CE website in the yellow pages and the Division of CHPE website.
3. Retain one copy for your files and bring the original typed worksheet to the Continuing Education Office in the SON when
meeting with the Primary/Lead Nurse Planner.
4. Initial planning meetings with the Director of Continuing Education (DCE) in the SON must occur at least 45 days prior to
the activity presentation date.
5. Final planning meeting must take place at least 30 days prior to the presentation date to allow time to process all necessary
paperwork. Exceptions to these instructions may be made only if unusual circumstances prevent planning within this time
frame. Requests for exceptions must be made in writing, with an explanation of the circumstances which prevent
compliance with the deadline for planning to the Director of Continuing Education in the SON.
I. Demographic Data:
Title of Program:
Date forms completed:
one time
Date of activity:
Location/Room#:
Hours Awarded:
City/State:
repeat dates:
Registration Fee
Contact Hours Planned
Registered Nurse Planner/Coordinator: List below in box after DCE
Other Planners:
Committee Member Name &
Contact Information
Credentials
Degrees
P. Renée Williams, Director of CE
PhD, RN, CCE
BSN, MSN, PhD
984-6227; rwilliams@umc.edu
Contact
Role on Committee
Primary/Lead Nurse Planner
Nurse Planner/Coordinator
Nurse Planner
Select one.
Select one.
II.
Design: Live
Webinar
Module
Audio/Video
Other
2013 SON CE Planning Form for Educational Activities
Page 1 of 5
Assessment of Learner needs: (p. 1) Check method(s) used: ____Survey _____Previous
Evaluations_____ Staff Request _____Other:__________________________________
2. Identify the appropriate gap for the intended target audience that this educational activity will address
based on needs assessment data: Review Section IV.B. to be completed with the DCE at planning
meeting.
Gap in Knowledge (knows)
Gap in Skills (knows how)
Gap in Practice (shows/does)
Other - Describe:
Description of current state:___________________________________________
Description of desired/achievable state: ________________________________________
B. Target Audience: Level of EducationPractice Area/SpecialtyGeographical Area-
Identify the target audience:
All RNs
Advance Practice RNs
RNs in Specialty Areas (Identify Specialty) :
LPNs
Interprofessional (Describe):
Other - (Describe):
C. Faculty/Presenter/Author (Complete Attachment A for each)
Faculty/Presenter/Author Name
Credentials
Degrees
D. Overall Purpose: (Complete on Attachment B Form)
E. Objectives/Content (Complete on Attachment B Form)
F. Teaching method: Lecture – Discussion- Group work –Role Play- Other____________
G. Evaluation: (Survey Monkey evaluations provided by UMMC Division of CE)____
H. Verify participation: ______Sign in ____Badge scanner __Other_______________
I. Successful completion (p.7) ______Must attend entire session _______Partial credit- (if
yes, must complete Section IV H.3).
III. Marketing/Advertisement (p.7)_____Flyer/Brochure ____Other______________________
A. Please attach copy of Flyer and the Program Agenda before posting for advertisement.
IV. Commercial Support: ____No ____Yes (if yes, must complete Section X of planning form
after meeting with the DCE)
V. Co-provided: No
2013 SON CE Planning Form for Educational Activities
Page 2 of 5
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER SCHOOL OF NURSING
For CE Office Use Only:
Sponsoring Department(s):
Maximum number expected to attend:
Please attach an agenda of the program.
A current curriculum vita for all course speakers must be attached when submitting application. This curriculum vita cannot be used
in lieu of completing Attachment A. Both an Attachment A and a current curriculum vita are needed on each speaker.
Do you anticipate funding from any source other than registration fees?
Yes
No
If yes, list name(s) of
contributor(s) and amount of money or other assistance pledged. Pledges and Educational Grants must be confirmed in writing to
CHPE.
For CE Office Use:
______________________________________________________________________
Nurse Planner/Coordinator
_____________________________
Date
_______________________________________________________________________
P. Renée Williams, PhD, RN, CCE
UMMC School of Nursing Administrator
_____________________________
Date
_______________________________________________________________________
Director/Pharmacy Prof Dev:
_____________________________
Date
_______________________________________________________________________
Social Work Liaison:
______________________________
Date
Approved by:____________________________________________________________
Elizabeth Franklin, PhD
Director, Continuing Health Professional Education
_______________________________
Date
CHPE Office Use Only
MNF = _____
CHPE = _____
CEU = _____
2013 SON CE Planning Form for Educational Activities
Page 3 of 5
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER SCHOOL OF NURSING
NURSING ATTACHMENT A
Lead Nurse Planner-Director of CNE
Planner ( target audience expert)
Presenter
Name:
Title of Activity:
Date of Presentation:
Biographical Data
Degree
Year
Present Employer
Institution
Title
Description
Vested Interest
I.
Have you received anything of value from a commercial supporter, which may be perceived as direct
or indirect interest in the subject(s) you are addressing in this education activity?
NO
II.
YES – List the commercial supporter:
If there is a commercial supporter, please describe your relationship:
speaker’s bureau
major stockholder
large gift(s)
grant/research support
no relationship
other, please describe:
shareholder
consultant
III.
Describe professional experience or areas of expertise in 4-5 sentences, including information
related to involvement in continuing nursing education; and (add 1-2 publications, if applicable)
IV.
During your presentation, will you include discussion of an unlabeled or the investigational use of a
product, device or drug that has not been approved by the FDA, for the use being presented in this
education activity?
NO
YES - *Explain:
* If yes, you must disclose this information during your presentation.
Select which method:
verbally during presentation
handouts
other
audiovisuals
*How will conflict of interest be resolved?
V.
Identify how you, as the presenter/content specialist/planner, took part in the planning and
evaluation of this activity:
planned objectives/content
planned time frame
planned teaching strategies
attended committee meetings
Signature of Planner/Presenter/Content Specialist
(Vested Interest/Disclosure Form)
reviewed evaluation summary
will utilize evaluation to revise presentation as needed
received up-to-date ANCC Accreditation standards
other
______________
Date
Rev 6/11
2013 SON CE Planning Form for Educational Activities
Page 4 of 5
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER SCHOOL OF NURSING
ATTACHMENT B
Educational Design I - Live
Title of Activity:
Overall Purpose:
Gap to be addressed by this activity:
Objectives
Contact Hours:
Knowledge
Skills
Practice
Content
Other: Describe_________________________________
Time Frames
Presenter(s)
Teaching
Strategies/Resources
List learner’s objectives in behavioral terms
Provide an outline of the content for each . Provide time frame for each . List presenter(s) for each objective Describe the teaching methods,
At the end of this activity the learner will be able to: objective. It must be more than a
objective. Include break and
strategies, materials, & resources
meal
times.
for each objectives
restatement of the objective.
At the end of this activity the learner will be able to:
Presentation 1:
Objective 1:
Objective 2:
Date:
Objective 1 Content:
A.
B.
Objective 2 Content:
A.
B.
Presentation 2:
Objective 3:
Objective 4:
Etc.
Evaluation
Objective 3 Content:
A.
B.
Objective 4 Content:
A.
B.
10 min
EVALUATION TIME IN MINUTES_________plus TOTAL ACTIVITY TIME IN MINUTES=
divided by 60 =
contact hour(s)
Updated 1/01/2013