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Application for Provider Unit Approval
(For new and renewing Providers)
New Hampshire Nurses’ Association
Commission on Continuing Education
NHNA
25 Hall St. Unit 1E
Concord, NH 03301
www.nhnurses.org
office@nhnurses.org
(603) 225-3783
January 2013
NHNA Provider Application
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New Hampshire Nurses Association
Application for Provider Unit Approval (2009 Criteria)
NOTE to Renewing Providers: Please ignore sections for first time applicants
INSTRUCTIONS TO FIRST TIME APPLICANTS TO BECOME APPROVED
PROVIDERS
Before applying, you must complete and submit an Intent to Apply Form to
validate eligibility for approved provider status. Once NHNA verifies your eligibility
you may submit the application and the fee to become a provider unit. There is a
90-day processing period.
For All applicants: Review instructions before completing application.
Sample forms are available for download on the NHNA website on the Commission
for Continuing Education page, including
 Biographical Data and Conflict of Interest Form

Activity Documentation Form

Sample Contact Hour Validation Certificate

Sample Participant Evaluation Form
Other resources: ANCC Accreditation Application Manual, 2013
Blooms Taxonomy (from NHNA website)
Guidelines for Writing Learning Objectives (from NHNA website)
APPROVED PROVIDER RESPONSIBILITIES
1. The operational requirements and the criteria outlined by NHNA Commission on
Continuing Education (NHNA CCE) are to be implemented throughout the threeyear approval period. These requirements are very specifically related to
professional standards and adult learning principles. The provider unit is
accountable for maintaining the integrity and quality of continuing nursing
education activities.
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2. It is the responsibility of the provider unit to be aware of when the approval period
begins and expires. If the provider unit wishes to continue provider status, an
application is to be received at the NHNA office three months before the expiration
date. If this does not occur, the provider unit's ability to continue to offer contact
hours for continuing education activities will end on the expiration date. It is
required that NHNA be kept informed of the current contact person for the provider
unit, and the correct contact information, (email, phone, and address).
3. NHNA CCE monitors the approved providers by requiring Interim Reports. For
new providers, this is due at nine months after approval status is given, and also
at 18 months. Although most re-approved providers will only be required to
submit an interim report at 18 months, the commission has the right to request
more frequent reports from providers when the need is identified. The NHNA
office will inform the provider when their Interim Report is due.
APPLICATION FEE: $1650.00
The application fee for potential approved providers is $1,650.00 for a three-year period. The
fee is to be paid at the time of the application. Once the application has been distributed to the
reviewers the fee is non-refundable.
EXTENSION FEE:
$100.00 per 30 days, to $300 for 90 days.
An application for renewal must be submitted to the CCE 90 days before the current approval
period expires to allow reviewers time to complete the process. If an application is late, the first
30 days will be $100. If an application is more than 30 days late but less than 60 days late it
will be a $200 late fee. If it is more than 60 days but less than 90, it will be $300. If an
application is later than 90 days, (submitted on or after the current expiration date, the
providership will be suspended. The $300 late fee will apply and no contact hours may be
awarded until the application is approved.
Members of the Commission on Continuing Education are available for consultation regarding
questions about the application preparation. For any assistance, please contact the NHNA
office at (603) 225-3783.
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DIRECTIONS: Some of the information will be typed directly into the form; some will need to be attached. If
more space is needed than provided on the form in any section, clearly identify where to find the continuation.
Submit an electronic version of the application and one paper copy, typed and collated in a three ring binder, and
the application fee. The application must include a table of contents and have pages clearly numbered
consistent with the table of contents. (If an electronic version is not possible, then submit two additional paper
copies without the binder.)
Date of this application:
Name of organization:
Address:
Identify the person with whom NHNA should correspond.
Contact person:
Title or position:
Role in provider unit:
Administrator:
Primary Nurse Planner:
Other (Specify):
Phone Number with area code:
Fax Number:
Email:
For provider units that have been previously approved as a provider through NHNA, please update any changes
related to staff:
Changes?
Yes
No
If yes, please note changes:
Degrees, certifications achieved
New staff
Former staff
Job/title changes
Administrative changes
Other: (specify)
Please provide detail related to changes noted:
FIRST TIME APPLICANTS:
Applicants seeking approval as a provider of continuing education in nursing must meet the following ANCC
criteria:
1. Duration- the provider unit must have been operational for a minimum of six months
2. Activities: The provider unit must have planned, implemented, and evaluated at least three
educational activities (not three sessions of the same conference) (a) with the direct involvement of
a designated Nurse Planner (as specified above), and (b) that adhere to the relevant criteria of the
ANCC Accreditation Program. Each learning activity must be at least one hour (60 minutes) in
length. Co-provided activities may not be counted as one of these three activities. However, an
activity approved by an ANCC-accredited approver unit may be counted in the three activities.
Organizational Overview
Organizational Overview 1: Demographics
A. Please submit a description of the features of the Approved Provider Unit including but not limited
to:
 Scope of services
 Size
 Target audiences
 Types of educational activities offered
 If part of a multi focused org., describe the relationship of these scope dimensions
to the total organization
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B. Our provider unit is: (check one)
A free-standing organization
Part of a larger organization: the organization does more than provide continuing education.
C. The geographic range of our provider unit is (where we target more than 50% of our marketing):
Our facility
Our city
Our county
Our state
Our region (NH, ME, VT, MA, CT, RI)
NOTE: If you target the marketing for more than 50% of your learning activities to people outside this
region, you are NOT eligible to apply as a provider. Please contact the NHNA Commission on
Continuing Education for additional information.
Organizational Overview 2: Lines of authority and Administrative Support
A. Submit a list including names and credentials, positions, and titles of the Primary Nurse Planner,
other Nurse Planner(s) if any, and all key personnel in the Provider Unit.
B. Submit position descriptions for the Primary Nurse Planner, other Nurse Planners (if any) and all
key personnel in the Provider Unit
C. Submit a chart depicting the structure of the provider unit including the Primary Nurse Planner,
other Nurse Planners(s) if any, and all key personnel
D. If part of a larger organization, submit an organizational chart, flow sheet, or similar image that
depicts the organization structure and the Provider Unit’s location within the organization
Organizational Overview 3: Data Collection and Reporting
A. Submit the completed Accredited Provider Continuing Education Summary of all CNE offerings
provided in the past 12 months. This is the annual report form completed by present providers.
Organizational Overview 4: Evidence
A. List the Provider Unit’s strategic goals with respect to CNE for the past 12 months.
B. Submit a list of the quality outcomes measures the Provider Unit collects, monitors, and evaluates
specific to the Provider Unit
C. Submit a list of the quality outcome measures that the Provider Unit collects, monitors, and
evaluates specific to Nursing Professional Development
Structural Capacity
Structural Capacity 1: Commitment
A. The Primary Nurse Planner’s commitment to learner needs, including how Provider Unit Goals are
revised based on data.
B. If the Provider Unit is part of a larger organization, how the organization’s leadership is committed
to supporting the goals of the Provider Unit.
Structural Capacity 2: Accountability
A. How the Primary Nurse Planner is accountable for resolving issues related to providing CNE.
B. How the Primary Nurse Planner ensures that all Nurse Planners and key personnel of the Provider
Unit are appropriately oriented/ trained to understand and adhere to the ANCC accreditation
criteria.
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Structural Capacity 3: Leadership
A. How the Primary Nurse Planner ensures that every Nurse Planner maintains accreditation
standards and guides the Planning Committee or team for an individual activity.
B. How the Primary Nurse Planner advocates for resources to ensure that the Provider Unit achieves
its goals related to quality outcomes measures.
Educational Design Process
The provider unit must have planned, implemented, and evaluated at least three educational activities (not
three sessions of the same conference) (a) with the direct involvement of a Primary Nurse Planner (b) that
adhere to the relevant criteria of the ANCC Accreditation Program. Co-provided activities may not be counted
as one of these three activities. However, an activity approved by an ANCC-accredited approver unit may be
counted in the three activities.
Learning activity development, implementation, and evaluation.
Submit documentation for three sample activities that have been planned within the 12 months of the application
date and comply with ANCC criteria. Include documentation form with all required attachments (see ANCC 2013
manual, Chapter 6, pages 78-86 for required evidence)
1. Assessment of learner needs
2. How the Nurse Planner uses the data collected to develop an educational activity that addresses
the identified gap
3. Qualified planners and faculty- the process used to be selected and why they were chosen
4. The process used to identify all actual or potential conflicts of interest for planning members,
reviewers, presenters, and authors. The process for resolution if applicable
5. The process used in the planning phase of successful completion requirements
6. How measurable objectives were developed that address a change in nursing practice or nursing
professional development.
7. How the teaching methods were chosen that are appropriate to achieve the purpose and the
objectives of the activity.
8. How the content of the educational activity is selected based on best available current evidence
9. How content integrity is maintained for CNE activities including what precautions are taken to
prevent bias and how those precautions are implemented
10. Awarding of contact hours
11. Activity evaluation and how the data will be used to guide further activities
12. How evaluation data were collected to measure change in nursing practice or nursing professional
development
13. Approval statements * See below for correct wording for official statement for offering contact
hours.
14. Documentation of completion
15. Sponsorship and commercial support guidelines
16. Disclosures provided to activity participants
FIRST TIME APPLICANTS:
*Please note that first time applicants will need to provide a sample of certificate of completion, as it would
appear following approval, containing the appropriate approval statements.
Correct ANCC Approved Provider Statement:
(Name of approved provider) is an approved provider of continuing nursing education by New
Hampshire Nurses’ Association’s Commission on Continuing Education, an accredited approver by the
American Nurses Credentialing Center’s Commission on Accreditation.
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Any time that promotional materials mention nursing contact hours, it is an ANCC requirement that the official
ANCC statement (above) be included on the promotional material. It is also required that no text is added to
the lines that the statement occupies. The value of the contact hours is not to be added to the statement and
must be on a separate line from the statement if it appears. This applies to all promotional material,
including: brochures, flyers, posters, emails, etc.
Quality Outcomes
The approved Provider Unit engages in an ongoing evaluation process to analyze its overall effectiveness
in fulfilling its goals and operational requirements to provide quality CNE. Describe using an example to
demonstrate the following:
Approved Provider Unit Evaluation
A. Describe the process utilized for evaluating effectiveness of the Provider Unit in delivering Quality
CNE.
B. Describe the how the evaluation process for the provider unit resulted in the development or
improvement of an identified quality outcome measure. (Refer to your units’ strategic goals in the past
12 months with respect to CNE for the past 12 months.)
Approved Provider Unit Evaluation Participants
The Approved Provider Unit shall include a variety of stakeholders, comprising those with vested interest
in the Approved Provider Unit outcomes in the evaluation process.
A. Describe why the Approved Provider Unit selects specific stakeholders to participate in the evaluation
process.
Approved Provider Unit Quality Outcome Measures
The Approved Provider Unit must demonstrate quality improvement efforts including identifying strategies
for working on targeted goals, evaluating progress towards those goals and revising or establishing new
goals.
A. Describe and using an example of how input from the stakeholders resulted in development of or
an improvement in quality outcome measures for the Approved Provider Unit.
Value/Benefit to Nursing Professional Development
Describe using an example how over the past 12 months the Approved Provider Unit has enhanced
nursing professional development.
Commercial Support
The Provider Unit must have a written policy or procedure and a signed written agreement if commercial
support or sponsorship is accepted.
Co-Provided Activities
Co-provided activities are conducted with the approved provider maintaining responsibility for:

Determination of educational objectives and content

Selection of content specialist planners & activity presenter(s)

Awarding of contact hours

Recordkeeping procedures

Evaluation methods and categories

Management of sponsorship and/or commercial support
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The provider unit complies with all applicable local, regional, state, and national laws and regulations
and operates its business in an ethical manner. Please provide attestation statement.
Signature of primary nurse planner (required):
Other signatures appropriate to provider unit (if any):
Thank you for completing this application for provider unit approval. Submit the application form, along
with your three sample activities, to the New Hampshire Nurses Association, 25 Hall Street, Unit 1E,
Concord, NH 03301.
You will receive confirmation that your materials have been received at NHNA and will be notified if the
Commission on Continuing Education needs any additional information before review. The application will
be assigned to two reviewers after assessment for any potential conflict of interest. The lead reviewer of
the application will contact you. Once the application review has been completed, you will be informed of
the action on your application.
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New Hampshire Nurses Association
Biographical Form for Provider Unit Personnel
Instructions: Complete this form for all personnel involved in the provider unit – nurse planners, reviewers,
and others. Copy as needed. This form is only used with the provider application. Use the full
biographical data form for individual activities.
Date:
Name, Degrees & Credentials:
Home Address OR Business Address:
Day Telephone:
Email Address:
Present Position (Title) & Employer:
My role in the provider unit is as:
Lead Nurse Planner
Nurse Planner
If RN, nursing degree(s): (check all that apply)
AD
Diploma
BSN
Masters
Doctorate
Administrator
Administrative Assistant
Other: (Describe)
My responsibilities/expertise for the provider unit include:
NHNA Provider Application