Louisana State Nurses Association
5713 Superior Drive, Suite A-6
Baton Rouge, Louisiana 70816
225-201-0993 and 225-201-0971(fax)
lsna@lsna.org
Application for Provider-Directed CNE Activity
A.
General Directions:
1.
Obtain an “Application for the Provider-Directed Activity” form from LSNA or the website
(lsna@lsna.org). Current forms must be used when submitting an application.
2.
Refer to the step-by-step instructions in Part B to complete each section of the Application.
3.
Fill in all information requested. The material submitted to LSNA must be typed in the format provided.
The sample forms may be copied and adapted as long as requested information is provided.
4.
Attach the following:
 Completed biographical data forms for each planning committee member and each faculty
including conflict of interest disclosures.(Do not send CVs or resumes.)
 Completed Educational Activity Content Outline
 Signed Demographic Data Sheet
 Signature of the administratively responsible person
 Evaluation form
 Advertising materials
 Certificate
 Fee
5.
Submit an electronic copy to lsna@lsna.org and mail four (4) complete, typed, collated copies of
the entire application including attachments as indicated above to: Louisiana State Nurses Association,
5713 Superior. Drive, Suite A.-6, Baton Rouge, LA 70816.
6.
Applications must be received at least 45 days before the date of the activity. An application fee of
$100.00 + $10 for each contact hour must be included.
7.
If the activity is approved, it can be presented as often as desired during the two-year approval period
unless substantial changes are made.
8.
For additional information, contact LSNA at (225) 201-0995 or 1-800-457-6378.
B.
General Information for Completing Application
1.
American Nurses Credentialing Center’s Commission on Accreditation criteria is used by the Louisiana
State Nurses Association to evaluate and approve provider directed continuing nursing education.
2.
Demographic Data
Submit the title, date of the event(s), number of contact hours requested, and the
organization/individual/facility requesting approval. Be sure to give complete contact information. The
date of the activity must be in the future, since no retroactive approval is ever allowed. If you are not
certain of the date, state when it might be scheduled in the future (for example: “To be scheduled once
approval received.” or “To be scheduled after mm/dd/yyyy. [in future]”). Remember to notify LSNA
in writing once the date is scheduled.
3.
Generally, the applicant name is the name of an organization, not the name of the person submitting the
application. The person submitting the application must sign on page 3 of the application.
4.
The person administratively responsible must read the LSNA CNE Activity Agreement and sign on
page 3 of the application.
PROVIDER-DIRECTED APPLICATION page 1
Louisiana State Nurses Association
Application for Approval of Provider-Directed Activity
General Information: Louisiana State Nurses Association (LSNA) is accredited as Provider and Approver
of Continuing Nursing Education by the American Nurses Credentialing Center’s (ANCC) Commission on
Accreditation (COA). LSNA adheres to the criteria established by the ANCC for continuing nursing education
and Educational Design Criterion and key elements established by the ANCC-COA. Sponsors of continuing
nursing education who choose to participate in the LSNA continuing nursing education approval process will
be expected to document compliance with all ANCC-COA education design criterion by providing all of the
information requested in this application.
Directions: Refer to, “American Nurses Credentialing Center COA Criteria for Provider-Directed
Continuing Nursing Education Approved by LSNA”, for specific guidelines. All information must be
completed in this format to be considered for review. The application itself can be copied in its entirety.
Adapted forms must contain all currently required information.These forms must be submitted. For
additional information, contact LSNA at (225) 201-0955 or 1-800-457-6378.
Submit an electronic copy to lsna@lsna.org and mail four (4) complete, typed, collated copies of the
entire application and attachments to: Louisiana State Nurses Association, 5713 Superior Drive, Suite
A-6, Baton Rouge, LA 70816.
Applications MUST be received at least 45 days before the date of the activity. An application fee of $100.00 +
$10.00 for each contact hour must accompany the application. If the activity is approved, it can be presented for a
two-year period without additional approval, providing no substantial changes are made.
DEMOGRAPHIC DATA (Corresponding information found in Section I, Instructions, page 1):
Title of activity:
Date of activity:
Contact Hours Requested:
Type of Activity:
Fee Enclosed:
Seminar/Workshop
Distance Learning via Computer
Conference
Distance Learning via Tele/Audio Conference
Other: Describe:
Organization submitting application:
Address:
LSNA/CNE Agreement:
Permission is hereby given to LSNA to release all information contained in this activity to ANCC and the
name, date, and location of the activity to interested parties.
I agree to maintain timely communication with LSNA by providing any reports or clarifications requested.
LSNA is to be notified of any changes to the program before the program date.
Individual submitting application:
Email address:
Telephone number:
Fax number:
Date
PROVIDER-DIRECTED APPLICATION page 2
FOR OFFICE USE ONLY
Date application received:
Fee
Activity #
How Paid
Application accepted for review
Date out for review
Application rejected for review
Reason for rejection:
Names of reviewers:
Committee decision: Approve ______
Denied
Defer Action
Recommendations
Revisions Received:
No Recommendations
Approve until
Agency notified (Initials and date)
Revisions of previously approved activity
PROVIDER-DIRECTED APPLICATION page 3
Please refer to the American Nurses Credentialing Center COA Criteria for Provider-Directed
Continuing Nursing Education Approved by LSNA for clarification for each item.
KE1. Target Audience and Needs Assessment
1. This activity was designed at the Registered Nurse level: Yes _____ No
2. This activity was designed at the APRN level: Yes
No
If yes, see pages 10 and 11 of Instruction for additional information.
3. Are others expected to attend?
Yes
No
If yes, please list:
4. Check the best description of type(s) of needs assessment used (check all the apply):
Annual Needs Assessment
Learners/Management requested event
Quality Studies/Risk Management Reports indicated need
Trends in literature, law and health care indicated need
Evidence-Based Practice
Other – Describe:
KE2. Qualified Planners and Faculty
1. Person administratively responsible: Provide the following information for the person responsible
for administering & retrieving all data for this activity and is in agreement with the LSNA CNE
Agreement on page LSNA will correspond with this person as primary contact.
Name & Credentials:
Address (This address will be used for all mailings)
Daytime Phone Number:
Fax Number:
Extension
Email:
Signature:
2. Planning Committee: Each educational activity is planned collaboratively by at least one
designated nurse planner who is a registered nurse who holds at least a baccalaureate degree in
nursing and has education or experience in the field of education or adult learning and an
additional RN planning committee member. Each member of the planning group should represent
at least one of the following areas: the relevant content expertise; the target audience; nurse
planner/responsibility for adherence to ANCC and LSNA approval criteria. Each planning
committee must have representation of all of these three areas. A member may represent more
than one role; however the content expert may not represent the target audience. The Nurse
Planner contributes oversight and must be actively involved in both the planning and the analysis
of evaluation data for the educational activity. The designated nurse planner is responsible for
adhering to ANCC criteria.
Activities specifically planned for APRN’s with prescriptive authority require that an APRN
be a member of the planning committee
APRN, if applicable
.
Designated Nurse Planner with a minimum of BSN/Responsible for adherence to ANCC/LSNA
guidelines:
_______
PROVIDER-DIRECTED APPLICATION page 4
Others:
Additional RN
Representing target audience
Content expert
BIOGRAPHICAL DATA FORM FOR EACH PLANNING MEMBER ATTACHED
3. Faculty:
List the names, degrees and credentials of each presenter/content specialist below. Attach an
additional sheet, if necessary. Attach completed Biographical Data Form for each presenter.
A.
B.
C.
D.
BIOGRAPHICAL DATA FORM FOR EACH PRESENTER ATTACHED
KE3. Effective Design Principles: Effective Design Principles are documented on the Educational
Activity Content Outline to provide information concerning educational objectives, content,
time frame, and teaching-learning strategies. Either version of the outline, landscape or
portrait orientation, may be used, but use the same version for the entire application. Use as
many additional copies of this page as necessary, numbered sequentially.
a. Purpose
b. Identify gaps in knowledge, skills, and practice identified (based on the needs assessment)
which the activity is designed to address.
c. Educational Objectives
1.Indicate what the participant will be able to do at the conclusion of the activity. An average
of 1-2 objectives per hour is realistic. It is also recommended that objectives be numbered
sequentially.Objectives must be singular, measurable and expressed in behavioral terms.
d. Content Congruent with Purpose and Educational Objectives
1.Itemize key points that will be addressed with each objective. Content must be more than
a restatement of the objectives, must be related to the objective, and put in outline form next
to the corresponding objective.
2.List number of minutes for each objective or topic.
e. Teaching-Learning Strategies Congruent with Purpose, the Activity’s Objectives and
Content
PROVIDER-DIRECTED APPLICATION page 5
List the Methods, Strategies, Materials and Resources to be used by faculty to cover each
objective. If Microsoft Powerpoint is used to develop slides for the program, please indicate as
slides under Teaching Methods.
f. Applicant must identify criteria for judging successful completion of the activity is consistent
with the learning goal (purpose), objectives, and teaching and learning strategies.
Successful completion of the activity will be verified by which of the following?
Sign-in sheets / attendance sheets
Internet registration
Other - Describe:
g. Applicant must determine method for verifying participation in the activity.
Which of the following criteria will be utilized to verify participation in the activity?
Attendance at entire activity
Completion / submission of evaluation form
Achieving passing score on post-test
Other - Describe:
By what means will the participant be informed of the criteria for successful completion of
the activity?
Information on brochure / advertising materials
Verbal statement at beginning of activity
Written information on handouts / website
Other - Describe:
KE4.
Awarding Contact Hour
Provide supportive documentation of the rationale used to determine the number of contact hours
to be awarded (spreadsheet, agenda, etc.) Contact hour is defined as 60 minutes. Contact hours may
be awarded in fractions. The minimum fraction of a contact hour for LSNA is 30 minutes or 0.5
contact hour. If ‘rounding’ is desired in the calculation of contact hours, the provider is to round
down to the nearest 1/100th. (EX) 45 minutes equals 0.75 contact hours
Agenda needs to be submitted with breakdown of educational activity and how contact hours were
calculated.
KE5.
Activity Evaluation
1.Check the method(s) of evaluation to be used (check all that apply)
Evaluation Form (required for all events)
Pre and/or Post test (optional) If post-test is used, what is the passing score?
Return demonstration (optional)
Other - Describe
2. Submit a copy of the evaluation tool(s) to be used for this event. It must include, at a minimum,
the following:
a. participants achievements of each objective
b. presenter’s knowledge of content, presentation skills, and organization f content.
c. category of evaluation (i.e. learner satisfaction, knowledge enhancement, skill and
attitude change, change in practice/performance, relationship of the practice change to
quality of service.
PROVIDER-DIRECTED APPLICATION page 6
d. plan to implement/utilize new information
e. opportunity to indicate awareness of conflict of interest
f. opportunity to indicate that program was presented in a fair, unbiased manner
3. Check the best description or describe how evaluation data will be used:
To refine future presentations of this course
To create new programs
To continue/discontinue the activity
To decide whether or not to change this faculty or facility
Other - Describe:
4. Learner Feedback: Check the best description or describe how learner will be provided feedback:
Questions and answers during the activity
Results of testing returned
Certificate
Follow-up communication
Other - Describe:
5.
Describe the quality improvement (QI) process to be used with this activity. May attach the
form to be used.
KE6. Accreditation Statement
Marketing materials, certificates, and any other documents must contain the official accreditation
statement. The accreditation statement must stand alone.
This provider-directed continuing nursing education activity is approved for __ contact hours
by LSNA.
Louisiana State Nurses Association is accredited as an approver of continuing nursing
education by the American Nurses Credentialing Center’s COA.
1.
Which of the following advertising materials will be used for the activity? (Check all that
apply)
Flyer / Brochure
Memo / Letter
Meeting Notice
E-mail (print hard copy to include with your application)
Website (Print hard copy to include with your application)
Other - Describe:
2.
A copy of the advertising material is included. If a mock-up is sent with this application, the
final copy will be sent as soon as it is printed. If advertising is via website, include the address
so that the reviewers can find this information. (Include a copy of the relevant pages of the
website with each copy of the application)
Website address:
PROVIDER-DIRECTED APPLICATION page 7
KE7. Documentation of Completion
A completed sample of the certificate is included. Certificate of completion includes the
following:
A.Name of the participant learner
B. Name and address of the provider of the educational activity
C.Title and date of the educational activity
E. Official approval statement
F. Number of contact hours awarded
KE8. Sponsorship and Commercial Support
will not receive commercial support.
1.Commercial support has been provided by the following: (List name of representative, company
and company)
2.
Commercial support provided by these organizations does not influence the
objectives and content of this activity (PLEASE INITIAL ON THE LINE)
KE9.Conflict of Interest Guidelines
Each planner and faculty must declare if they have any conflict of interest on the Biographical Data
Form. If a conflict of interest is present, it should be disclosed on the Biographical Data Form. See
Attachment A. Use current LSNA biographical form 10/09.
If conflict of interests were identified, describe if the conflict was real or a potential bias or a
conflict of interest and how the conflict was resolved:
______ No, conflict of interests
______ Yes, conflict of interests. Describe resolution: _______________________________
KE10. Disclosures Provided to Activity Participants
Learners will be informed about: Requirements for Successful Completion , Conflicts of Interest,
Sponsorship or commercial support, Non-endorsement of products, and Off-label use by:
Information provided on advertising material.
Information on handouts distributed or slides presented at start of event.
______ Announcement at beginning of event.
Announcement that presenters have no conflict of interest
A sign displayed in the exhibit area.
Other - Describe:
KE11. Record-Keeping System
The applicant agrees to the following record-keeping criteria. Check each to indicate
willingness to comply.
All correspondence; completed copy of application which includes
(a) Planning
-description of the target audience
-the method and findings of the needs assessment
-names, titles, and expertise of the activity planners and presenters
PROVIDER-DIRECTED APPLICATION page 8
-conflict of interest disclosure statements from planners and presenters and resolutions
of conflict of interest, as appropriate
-learning goal (purpose), objectives and content
-instructional strategies, delivery methods, learner feedback mechanisms, and
resources to be used
-methods or process used to verify participation
-notice to learners identifying how successful completion will be measured
-marketing and promotional materials
-division of responsibilities among co-providers, if any,
-means of ensuring content integrity with commercial support, if any,
-written commercial support agreement as required in the standards of commercial
support for any activity receiving commercial support.
(b) Implementation:
-title, location, and date of the educational activity
-all evaluation tools used, including a summative evaluation
-participant names/sign in sheets
-sample certificate of completion, and
-number of contact hours associated with official accreditation statement awarded to
individual participants
-documentation of the verbal provision of required disclosures (see Standard 6A and
6B of the Standards for Commercial Support for further guidance.)
_____ Records of attendance; summative evaluation(s); & contact hours which will be
maintained in a retrievable file which is accessible to only authorized personnel for six (6)
years.
Records will be maintained confidentially.
Records will be filed and stored at (list location)
Other - Describe
BEFORE SENDING THIS APPLICATION TO THE LOUISIANA STATE NURSES
ASSOCIATION, PLEASE USE THE FOLLOWING CHECKLIST TO MAKE SURE THAT YOU
HAVE INCLUDED ALL NECESSARY MATERIALS FOR THIS ACTIVITY.
Submit an electronic copy to lsna@lsna.org and mail four (4) typed and collated copies of the
application and attachments.
Biographical data forms for each planning committee member and each faculty
_________ Educational Activity Content Outline
Evaluation form
Completed certificate
Advertising materials
Fee
PROVIDER-DIRECTED APPLICATION page 9