January 2016
TEXAS NURSES ASSOCIATION
8501 MoPac Expressway, Suite 400, Austin, Texas 78759
Phone: (512) 452-0645 Fax: (512) 323-5379 E-mail: cne@texasnurses.org
Web site: www.texasnurses.org
________________________________________________________________________________
APPROVED PROVIDER APPLICATION January, 2016
_________________________________________________________________________________
Prior to completing this application read all the “Approved Provider Application Criteria and
Guidelines,” and the “Application Submission Criteria” completely. All documentation requirements
must be met prior to approval. Information presented within this application is required to meet the Texas
Nurses Association (TNA) and the American Nurses Credentialing Center’s Commission on Accreditation
(ANCC COA) criteria for continuing nursing education. In addition, the objectives and content in your
activities must meet the definition and criteria of continuing nursing education as established by the Texas
Board of Nursing. The definition is found in the Texas Administrative Code, TITLE 22 EXAMINING
BOARDS, PART 11 TEXAS BOARD OF NURSING, CHAPTER 216 CONTINUING COMPETENCY, Rule
216.1 Definitions, (9) Continuing Education (CE). It reads as follows: “Programs beyond the basic
nursing preparation that are designed to promote and enrich knowledge, improve skills and develop
attitudes for the enhancement of nursing practice, thus improving health care to the public.”
Criteria for what is not CE can be found in Rule 216.6 – “Activities that are not acceptable as Continuing
Education”:
The following activities do not meet continuing education requirements for licensure renewal.
1- Basic Life Support (BLS) or cardiopulmonary resuscitation (CPR) courses.
2- Inservice programs. Programs sponsored by the employing agency to provide specific information
about the work setting and orientation or other programs which address the institution’s philosophy,
policies and procedures; on-the-job training; basic cardiopulmonary resuscitation; and equipment
demonstration are not acceptable for CNE credit.
3- Nursing refresher courses. Programs designed to update knowledge or current nursing theory and
clinical practice, which consist of a didactic and clinical component to ensure entry level
competencies into professional practice are not accepted for CNE credit.
4- Orientation programs. A program designed to introduce employees to the philosophy, goals,
policies, procedures, role expectations and physical facilities of a specific work place are not
acceptable for CNE credit.
5- Courses which focus upon self-improvement, changes in attitude, self-therapy, self-awareness,
weight loss, and yoga.
6- Economic courses for financial gain, e.g., investments, retirement, preparing resumes, and
techniques for job interview.
7- Courses which focus on personal appearance in nursing.
8- Liberal art courses in music, art, philosophy, and others when unrelated to patient/client care.
9- Courses designed for lay people.
Form 01102015
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January 2016
Fee schedule … $2,100 for three year Approved Provider Application
There will be a processing fee of $100 that is non-refundable should your application be withdrawn.
Review fees are non-refundable for all applicants unless they withdraw prior to review by the CNE Committee.
If the Primary Nurse Planner and/or an appropriate designee attended the Approved Provider Workshop within the
past 10 months, there is a $500 discount policy against the $2,100 effectively making the fee $1,600.
GENERAL INFORMATION: This application consists of an eligibility section, a demographic section and four
(4) sections that must be completed in their entirety. The application has been redesigned to add additional
space as needed for each required element. If you need to add additional information/documentation, clearly
label where the information continues. A table of contents with page numbers must be included. Each page
of the application, the appendices and the education activities or approval letters must be numbered in
sequence, beginning with page 1 on the “Eligibility Assessment” page. Submit three (3) typed copies of the
completed application. The original must be secured with a binder clip or rubber bands. Do not spiral bind any
of the applications three (3) copies, and do not put holes in the original copy. Each of the other two (2) copies
must be placed in its own loose-leaf notebook or three-ring binder. The original will be placed in the in-house
files where space is at a premium. The other two copies will be sent to the Nurse Peer Reviewers. Use tabs to
separate sections in all three copies. In addition, include a flash drive that contains your Approved Provider
application with each hard-copy application. Please proofread prior to submitting. Remove these first two
pages prior to making copies.
The information contained within this document is based upon the “2013 ANCC Primary Accreditation Application
Manual for Providers and Approvers” (2011) published by the American Nurses Credentialing Center’s Commission on
Accreditation (ANCC COA). Some of the information is excerpted and directly quoted from the ANCC COA
publication. All updates and changes from ANCC COA have been incorporated into this document.
The awarding of Approved Provider Unit status is the means whereby the Texas Nurses Association, an
accredited approver of continuing nursing education by the American Nurses Credentialing Center’s
Commission on Accreditation, grants public recognition to a CNE Approved Provider Unit that has met the
established standards for providing continuing nursing education activities.
Form 01102015
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January 2016
TEXAS NURSES ASSOCIATION
8501 MoPac Expressway, Suite 400, Austin, Texas 78759
Phone: (512) 452-0645 Fax: (512) 323-5379 E-mail: cne@texasnurses.org
Web site: www.texasnurses.org
January, 2016
APPROVED PROVIDER APPLICATION
ELIGIBILITY ASSESSMENT
1. Is your organization a commercial interest? A “Commercial Interest” is defined as any entity either
producing, marketing, reselling, or distributing health care goods or services consumed by, or used on,
patients; or that is owned or controlled by an entity that produces, markets, resells, or distributes health
care goods or services consumed by, or used on patients.
____ Yes – You may not apply to become/reapply as an Approved Provider Unit. Contact ANCC.
____ No – Continue to the next question.
2. Did your organization promote/market/advertise/target more than 50% of your education activities in
the past calendar year to registered nurses in multiple regions based on the Department of Health and
Human Services regions (i.e. outside of region 6 and its contiguous states)?
____ Yes – You may not apply to become/reapply as an Approved Provider Unit. Contact ANCC.
____ No – Continue to the next question.
3. Has this organization ever been denied accreditation by ANCC or had its accreditation status
suspended or revoked? Yes ____ No ____
If “Yes”, please provide the following information:
Date: ______________ Action:
Denied
Suspended
Revoked
Brief Description:
4. Has this organization ever been denied approval by or had approval suspended or revoked for an
individual activity or an Approved Provider application by the Texas Nurses Association?
Yes ____ No ____
If “Yes”, please provide the following information:
Date: ______________ Action:
Denied
Suspended
Revoked
Brief Description:
5. Has this organization ever been denied approval by or had approval suspended or revoked for an
individual activity or an Approved Provider application by another ANCC Accredited Approver?
Yes ____ No ____
If “Yes”, please provide the following information:
Date: ______________ Action:
Denied
Suspended
Revoked
Brief Description:
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January 2016
6. Are all Approved Provider Unit Nurse Planners currently licensed Registered Nurses with a
baccalaureate or higher degree in nursing?
Yes ____ No ____
If “No”, the applicant organization is not eligible for Approved Provider status.
7. Does the applicant organization have an identified Primary Nurse Planner who acts as the contact
with the ANCC Accredited Approver Unit, the Texas Nurses Association, and ensures compliance
with the ANCC/TNA criteria across the Approved Provider Unit?
Yes ____ No ____
If “yes”, provide Primary Nurse Planner’s Name and Credentials:
If “no”, the applicant organization is not eligible for Approved Provider status.
8. Do the Approved Provider Unit’s Nurse Planner(s) actively participate in the planning,
implementation and evaluation process of each continuing nursing education activity?
Yes ____ No ____
If “no”, the applicant organization is not eligible for Approved Provider status.
9. Has the applicant organization been operational for six (6) months using the ANCC/TNA criteria?
Yes ____ No ____
If “yes”, list the date the applicant organization became operational:
If “no”, the applicant organization is not eligible for Approved Provider status.
10. Has the applicant organization assessed, planned, implemented, and evaluated at least three (3)
separate education activities within the past 12 months, provided at separate and distinct events:
 With the direct involvement of the Nurse Planner;
 That adhere to the ANCC/TNA criteria; and
 Each being at least one(1) hour (60 minutes) in length;
Yes ____ No ____
If “no”, the applicant organization is not eligible for Approved Provider status.
11. Is the applicant organization in compliance with all federal, state, and local laws and regulations
that apply to the delivery of CNE?
Yes ____ No ____
If “no”, the applicant organization is not eligible for Approved Provider status.
12. Have you read the “Approved Provider Application Criteria and Guidelines”?
____ Yes – Please continue with the remainder of the application.
____ No – STOP! Go back and read the information in the “Approved Provider Application Criteria and
Guidelines”.
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January 2016
DEMOGRAPHIC DATA
Name of Organization/Approved Provider Unit:
(The name that appears here must be identical to the name that appears on the certificate of
successful completion and in the “Approval Statement” portion of the Operational Requirements
Attestation.)
Address:
(Street Address)
(City)
(State)
Main Phone Number: (
(Zip)
)
IDENTIFY ORGANIZATION TYPE:
_____ Constituent Member Associations of ANA
_____ College or University
_____ Healthcare Facility
_____ Health-Related Organization
_____ Multidisciplinary Educational Group
_____ Professional Nursing Education Group
_____ Specialty Nursing Organization
_____ Other _______________________________________
First time Approved Provider applicant (all applicants who are not currently Approved Providers)
Approved Provider Re-application: Current Approved Provider Number:_____________________
Identify the Primary Nurse Planner:
Primary Nurse Planner’s Name and Degrees/Credentials:
Title or position:
Phone number: (
Email address:
)
State in which licensed as an RN:
Alternate email address:
Identify a secondary contact person:
Name and Credentials:
Title or position:
Phone number: (
Email address:
)
Alternate email address:
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January 2016
Identify the person with whom we should correspond:
____ Primary Nurse Planner
____ Secondary contact person as listed above
____ Other
Name and Credentials:
Title or position:
Phone number: (
Email address:
)
Alternate email address:
Does your Approved Provider Unit have a publically accessible website that addresses your CNE
activities?
Yes ____ No ____
If “yes”, the address is:
Did your Primary Nurse Planner and/or an appropriate designee attend a TNA “Approved Provider
Workshop” within the past ten (10) months?
____ Primary Nurse Planner
Date attended
____ Designee
Date attended
____ Neither attended an “Approved Provider Workshop”
Are you a member of the TNA CNE Committee?
Yes ____ No ____
Date you submitted this application to TNA: _______________________________________
Form 01102015
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January 2016
CHECKLIST – Primary Nurse Planner to initial:
____ Application fee - $2100/$1600 – make checks payable to “Texas Nurses Association”.
____ Three (3) copies of the application with all attachments.
____ Three (3) USBs of the application as it is reflected in the hard copy application.
____ Application is typed. All pages, including the appendices and sample activities or approval letters,
are numbered. A detailed table of contents is included. All three (3) copies are appropriately
tabbed.
____ Application is printed one-sided.
____ Sample activities (for re-applications) have a date of first presentation from January, 2015 to
January, 2016, and meet the Texas Board of Nursing’s (BON) definition of and criteria for
continuing nursing education.
STATEMENT OF UNDERSTANDING
I attest, by my signature below, that I am duly authorized by (insert name of organization) to submit this application
as an Approved Provider and to make the statements herein. On behalf of (insert name of organization), I have
read the Approved Provider eligibility requirements and criteria. I understand that (insert name of organization) is
subject to all eligibility requirements and criteria as an Approved Provider. I understand that becoming an Approved
Provider depends on successfully meeting eligibility requirements and criteria and maintaining Approved Provider
standing is dependent upon continued compliance.
On behalf of (insert name of organization), I expressly acknowledge and agree that information accumulated
through the approval process may be used for statistical, research, and evaluation purposes and that anonymous
and aggregate data may be released to third parties. Otherwise, all information will be kept confidential and shall
not be used for any other purposes without (insert name of organization)’s permission.
On behalf of (insert name of organization), I hereby certify that the information provided on and with this application
is true, complete, and correct. I further attest, by my signature on behalf of (insert name of organization), that (insert
name of organization) will comply with all eligibility requirements and approval criteria throughout the entire approval
period, including all reapplication periods for maintaining approval, and that (insert name of organization) will notify
the Texas Nurses Association promptly if, for any reason while this application is pending or during any approval
period, (insert name of organization) does not maintain compliance. I understand that any misstatement of material
fact submitted on, with or in furtherance of this application for Approved Provider status shall be sufficient cause for
the Texas Nurses Association to deny, suspend or terminate (insert name of organization)’s Approved Provider
status and to take other appropriate action against (insert name of organization).
I confirm that my signature below indicates that (insert name of organization) is administratively and operationally
responsible for coordinating the entire process of planning, implementing and delivering CNE activities within the
Approved Provider Unit.
I confirm that my signature below indicates (insert name of organization)’s commitment to maintain all required records
for six (6) years in an easily retrievable, but confidential manner, available only to authorized personnel.
I hereby attest that (insert name of organization) adheres to all local, regional, state, and federal laws and regulations.
I further attest that this Approved Provider Unit maintains and follows business and management policies and
procedures to ensure its legal and ethical obligations and commitments – as they relate to human resources and
financial affairs – are met.
In the event (insert name of organization) wishes to appeal denial of this Approved Provider Application or a
subsequent revocation of their Approved Provider status, (insert name of organization) agrees to appeal in accordance
with the TNA Accredited Approver Unit appeal process (copies are available from the TNA Accredited Approver Unit)
and to accept the decision of the Appeal Panel as final and non-appealable.
Signature of Primary Nurse Planner
Date
Type or Print Full Name of Above:
Form 01102015
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January 2016
I.
APPROVED PROVIDER ORGANIZATIONAL OVERVIEW (OO)
Structural Capacity
OO1. Demographics
1.
Submit a description of the features of the Approved Provider Unit, including by not limited to
scope of services, size, geographic range, target audience(s), content areas, and the types of
education activities offered.
Description:
Scope of Services
Size of the Approved Provider Unit
Geographic range
RN target audience
Content areas
Types of activities offered
2.
Is the Approved Provider Unit part of a multi-focused organization?
Yes ____ No ____
If “yes”, describe the relationship of these scope dimensions to the total organization.
A. Describe the multi-focused organization.
B. Describe the relationship of the Approved Provider Unit to the multi-focused
organization based on the above features (001).
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January 2016
OO2. Lines of Authority and Administrative Support
1.
Submit a list by completing the information in the boxes below of all members of the
Approved Provider Unit to include the names and degrees and credentials, employment
positions, or titles of the Primary Nurse Planner, other Nurse Planner(s), and all key personnel
in the Approved Provider Unit.
2.
Submit position descriptions for the Primary Nurse Planner, Nurse Planners, and key
personnel in the Approved Provider Unit.
A.
Primary Nurse Planner:
Name and Degrees/Credentials:
Title or position:
Position description on page:
B.
Nurse Planner(s):
Name and Degrees/Credentials:
Title or position:
Position description on page:
(Repeat this area as often as necessary to completely list all Nurse Planners for your Approved Provider
Unit. If you serve as Primary Nurse Planner and as a Nurse Planner for your Approved Provider Unit,
include yourself in this section of the application also.)
C.
Key Personnel:
Name and Degrees/Credentials:
Title or position:
Position description on page:
(Repeat this area as often as necessary to completely list all Key Personnel for your Approved Provider Unit.
Please mark this area as N/A if no additional personnel are used by your Approved Provider Unit.)
3.
Submit an organizational chart depicting the structure of the Approved Provider Unit, including
the Primary Nurse Planner, other Nurse Planner(s) (if any), and all key personnel.
Page:
4.
If part of a larger organization, submit an organizational chart, flowchart, or similar image that
depicts the organizational structure and the Approved Provider Unit’s location within the
organization.
Page:
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January 2016
Educational Design Process
OO3. Data Collection and Reporting
Approved Provider organizations report data, at a minimum, annually to TNA.
1.
Submit a complete list of all CNE activities provided in the past 12 months, including activity
dates; titles; target audience; total number of participants; number of contact hours offered for
each activity; joint provider status; and any commercial support or sponsorship, including
monetary or in-kind amount(s).
Page:
 First time applicants: Submit current logs for your three (3) TNA approved individual
activities.
Page:
Quality Outcomes
OO4. Evidence
1.
List the Approved Provider Unit’s strategic goals with respect to CNE for the past 12 months.
List:
2.
Submit a list of the quality outcome measures the Approved Provider Unit collects, monitors,
and evaluates specific to the Approved Provider Unit.
List:
Submit a list of the quality outcome measures the Approved Provider Unit collects, monitors,
and evaluates specific to Nursing Professional Development.
List:
3.
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II.
APPROVED PROVIDER STRUCTURAL CAPACITY (SC)
A. Commitment. The Primary Nurse Planner demonstrates commitment to ensuring RNs’ learning needs
are met by evaluating the Approved Provider Unit’s goals in response to data that may include but is not
limited to aggregate individual educational activity evaluation results, stakeholder feedback (staff,
volunteers), and learner/customer feedback.
Describe and, using an example, demonstrate the following:
The Primary Nurse Planner’s commitment to learner needs, including how the Approved Provider
Unit processes are revised based on data.
A. Process Description (Procedure – How do you do it?):
SC1.
B. Specific Example:
NOTE: Complete SC2 only if the Approved Provider Unit is part of a larger organization.
How the organization’s leadership is committed to supporting the goals of the Approved Provider
Unit.
A. Process Description (Procedure – How do you do it?):
SC2.
B. Specific Example:
B. Accountability. The Primary Nurse Planner is accountable for ensuring that all Nurse Planners and
key personnel in the Approved Provider Unit adhere to ANCC/TNA criteria.
Describe and, using an example, demonstrate the following:
SC3.
How the Primary Nurse Planner ensures that all Nurse Planners and key personnel of the
Approved Provider Unit maintain adherence to ANCC/TNA criteria.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
SC4.
How the Primary Nurse Planner is accountable for resolving issues related to providing CNE.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
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C. Leadership. The Primary Nurse Planner demonstrates leadership of the Approved Provider Unit
through direction and guidance given to individuals involved in the process of assessing, planning,
implementing, and evaluating CNE activities in adherence with ANCC/TNA criteria.
Describe and, using an example, demonstrate the following:
SC5.
How the Primary Nurse Planner ensures that every Nurse Planner maintains ANCC/TNA
standards and guides the planning committee for an education activity.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
SC6.
How the Nurse Peer Review Leader of the Texas Nurses Association is used as a resource by
the Primary Nurse Planner and/or other Nurse Planner(s) in the Approved Provider Unit.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
D. Resources. The Primary Nurse Planner advocates for and utilizes available human, material, and
financial resources to ensure that the Approved Provider Unit achieves its goal of meeting identified
quality outcome measures.
Describe and, using an example, demonstrate the following:
SC7.
How the Primary Nurse Planner advocates for resources to ensure that the Approved Provider
Unit achieves it goals related to quality outcome measures.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
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III.
APPROVED PROVIDER EDUCATIONAL DESIGN PROCESS (EDP)
A. Assessment of Learning Needs. CNE activities are developed in response to, and with consideration
for, the unique educational needs of the Registered Nurse target audience.
Describe and, using an example, demonstrate the following:
EDP1. The Nurse Planner’s methods of assessing the current learning needs of the Registered Nurse
target audience.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP2. How the Nurse Planner uses data collected to develop an education activity that addresses the
identified gap in knowledge, skills, and/or practices.
A. Process Description (Procedure – How do you do it? ):
B. Specific Example:
B. Planning. Planning for each education activity must include one Nurse Planner and one other planner.
One of the planners must have appropriate subject matter expertise for the education activity.
Describe and, using an example, demonstrate the following:
EDP3. The process used to select a planning committee for an education activity, including why an
individual member was chosen.
A. Process Description (Procedure – How do you do it? ):
B. Specific Example:
EDP4. The process used to identify all actual and potential conflicts of interest for all members of the
planning committee, presenters, authors, and content reviewers.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP5. The process for resolution of an actual or potential conflict of interest and the outcome achieved.
A. Process Description (Procedure – How do you do it? ):
B. Specific Example:
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EDP6. The process utilized during the planning phase of the education activity to determine how
participants will successfully complete the learning activity.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
C. Design Principles. The educational design process incorporates measurable educational objectives,
best-available evidence, and appropriate instructional strategies.
Describe and, using an example, demonstrate the following:
EDP7. How measurable educational objectives are developed that address the change in nursing practice
or nursing professional development.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP8. How the content of the education activity is selected based on best-available current evidence (e.g.,
clinical guidelines, peer-reviewed journals, experts in the field).
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP9. How content integrity is maintained for CNE activities, including what precautions are taken to
prevent bias and how those precautions are implemented.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP10. In the presence of commercial support/sponsorship, how additional precautions are taken to
maintain content integrity for CNE activities, including what precautions are taken to prevent bias
and how those precautions are implemented.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP11. How instructional strategies are chosen that are appropriate to achieve the purpose and objectives
of the CNE activity.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
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D. Achievement of Objectives. A clearly defined method that includes learner input is used to evaluate
the effectiveness of each education activity. Results from the activity evaluation are used to guide future
activities.
Describe and, using an example, demonstrate the following:
EDP12. How summative evaluation data for an education activity were used to guide future activities.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
EDP13. How evaluation data were collected to measure change in nursing practice or nursing professional
development.
A. Process Description (Procedure – How do you do it? ):
B. Specific Example:
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IV. APPROVED PROVIDER QUALITY OUTCOMES (QO)
A. Approved Provider Unit Evaluation Process. The Approved Provider Unit must evaluate the
effectiveness of its overall functioning as an Approved Provider Unit.
Describe and, using an example, demonstrate the following:
QO1. The process utilized for evaluating effectiveness of the Approved Provider Unit in delivering quality
CNE.
A. Process Description:
What is
When is the
evaluated?
evaluation
done?
Triggers?
Procedures and
Forms
Material
Resources
Financial
Resources
Human
Resources
Activities
Who
participates in
the process?
How is the
evaluation
performed?
Data sources
Outcomes/
Results
Repeated
Activities
Progress towards
Unit goals
Progress towards
Unit quality
outcome
measures
How Unit is
enhancing nursing
professional
development
B. Specific Example:
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QO2. How the evaluation process for the Approved Provider Unit resulted in the development or
improvement of an identified quality outcome measure. (Tie to identified quality outcomes listed
in 004-2).
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
B. Approved Provider Unit Evaluation Participants. The Approved Provider Unit shall include a variety
of stakeholders, comprising those with a vested interest in the Approved Provider Unit outcomes, in the
evaluation process.
Describe and, using an example, demonstrate the following:
QO3. Why the Approved Provider Unit selects specific stakeholders to participate in the evaluation
process.
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
C. Approved Provider Unit Quality Outcome Measures. The Approved Provider Unit must demonstrate
quality improvement efforts including strategies for working on targeted goals, evaluating progress
toward goals, and revising or establishing new goals.
Describe and, using an example, demonstrate the following:
QO4. How input from stakeholders resulted in development of or an improvement in quality outcome
measures for the Approved Provider Unit. (Tie to identified quality outcomes listed in 004-2).
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
D. Value/Benefit to Nursing Professional Development. The Approved Provider Unit shall evaluate
data to determine how the Approved Provider Unit, through the learning activities it has provided, has
influenced the professional development of its RN learners.
Describe and, using an example, demonstrate the following:
QO5. How, over the past 12 months, the Approved Provider Unit has enhanced nursing professional
development. (Tie to quality outcomes listed in 004-3).
A. Process Description (Procedure – How do you do it?):
B. Specific Example:
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E. Operational Requirements Attestation: Provide an Operational Requirements Attestation statement that
the Approved Provider Unit must adhere to during the three-year period of approval. The Approved Provider
Unit Primary Nurse Planner must sign the attestation.
_____Page number(s) in the document or appendix where you have placed the signed Operational
Requirements Attestation.
F. Approved Provider Unit’s Forms: Provide a blank copy of the following forms that are utilized by the
Approved Provider Unit. (use September, 2014 forms)
Form
Page #

Biographical Data Form for Approved Provider Unit .....................................

Biographical Data Form for Activities.............................................................

Conflict of Interest Disclosure Form ..............................................................

Evaluation Tool (Provider-Directed)...............................................................

Evaluation Tool (Learner-Paced) ...................................................................

Attendance Verification Tool(s)......................................................................

Certificate of Successful Completion .............................................................

Promotional Materials (sample) .....................................................................

Disclosure to Participants ..............................................................................

Joint Providership Agreement ........................................................................

Commercial Support Agreement ...................................................................

Sponsorship Agreement ................................................................................

Commercial Support/Sponsorship Policy ......................................................
G. Three (3) Education Activities:
Re-applicants: Include three (3) sample activities. These activities should be from the past 12
months (January, 2015 – January, 2016). Don’t forget to include the evaluation summary and first
page of your attendance verification document for each of the three (3) activities.
First-time applicants: Include your three (3) TNA Individual Activity approval letters. Don’t forget
to include the evaluation summary for each of the three (3) activities and first page of your
attendance verification document for each of the three (3) activities.
[The last page of this application is a form used by the Nurse Peer Review team. Please complete Section I
in full. Please do not separate this form into two (2) pages.]
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January 2016
Approved Provider Application Decision Form
SECTION I.
Name of Organization:
(The organization name that appears here must be identical to the organization name that appears on the
front of this application.)
If you are re-applying, your current Approved Provider ID # ________________________________
Submitted Activities:
PD
LP
Title #1 _________________________________________________________
Title #2 _________________________________________________________
Title #3 _________________________________________________________
THIS ENTIRE PAGE SHOULD BE PLACED AT THE VERY END OF YOUR APPLICATION!
SECTION II. TO BE COMPLETED BY TNA NURSE PEER REVIEWER:
APPLICATION:
First Time
Re-application
SCORING:
Structural Capacity (SC):
Educational Design Process (EDP):
Quality Outcomes (QC):
COMMENTS:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
SAMPLE ACTIVITIES:
No.
#1
% Score
No.
#2
% Score
No.
#3
% Score
COMMENTS:
Average Score
(May use activity number from above for reference.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Review and Consultation time: Indicate date(s) and amount of time(s)
spent:
Individual
1st Consensus
Time with
Final Consensus
Review
Review
Applicant
Review
TOTAL: _________________
Reviewed by: ___________________________
REVIEWERS! This sheet must be removed from the application, and added to your evaluation
Formsheets
01102015 handed in to TNA.
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