CONTINUING NURSING EDUCATION (CNE)
APPROVAL APPLICATION / For Office Use Only
Code #
Reviewers
SUNA will accept program applications electronically (which is the preferred method) or by mail.
Email the complete program application to: or send 1 copy to the SUNA National Office, East Holly Ave. Box 56, Pitman, NJ 08071-0056 or overnight mailing address: 200 E. Holly Ave., Sewell, NJ 08080. Do not send by FAX. Handwritten applications will not be accepted.
Type of activity-select one: / Provider directed & paced (e.g. live in person or webinar)
Provider directed, learner paced (e.g. monograph, self learning module)
Title of Education Activity: / Interstitial Cystitis
Date(s) or beginning of Education Activity: / 3/20/2013
Do you plan to repeat this activity? Yes No If yes, when?
Has this educational activity ever been submitted to any other approver unit? Yes No If yes, was it approved or denied
If denied, state reason:
Provider (chapter name, organization, etc.): Lancing Chapter of SUNA Chapter #: 10053
I have read the policy “Eligibility to Use the Approver Unit” and validate that I do not represent a commercial entity.
The nurse planner has read and is familiar with the criteria in the SUNA Guidelines manual for CNE Approval: yes
Nurse Planner name: Heidi PowMSN, CRNP,
Contact Hours Requested (60 minutes per contact hour): 1.0 / Estimated Attendance/Participants: 35
Application Fee: $30 / Method of Payment : Check or Credit Card
Credit Card Information: Visa Master Card Amex
Credit Card # 4545-4445-4454-4544 Exp. Date 1/1/2015 Card Holders Name: Joe Pow
STOP! A COMPLETE PROGRAM APPLICATION CONTAIN THE FOLLOWING FORMS
Use this checklist to ensure you have included all necessary forms with your application
Instructions on how to complete each document and sample forms are available online at www.suna.org
CNE Approval Application plus fee / Copy of Contact Hour Certificate (SUNA or Other)
CNE Approval Documentation Form I / Attendance Roster (SUNA or Other)
CNE Approval Documentation Form II for each presenter & or content area / Disclosure Declaration Memorandum (SUNA or Other)
Biographical Data Form for all presenters and planning committee members (CV’s are NOT accepted) / Brochure or Advertisement of Activity
Commercial Support Form (if applicable) refers to shared financial contributions, not shared educational content planning
Vested Interest Form for all presenters, planning committee members and person(s) with influence in choosing the topic
or speaker / Sponsorship Agreement Form (if applicable) refers to shared financial contributions, not shared educational content planning
Co-Provider Form (if applicable) refers to shared financial contributions, not shared educational content planning
CNE Activity Evaluation forms (SUNA or Other)
Record Keeping: Records for this educational activity will be confidentially maintained for a period of six (6) years by:
Donna Back, Chapter President, 14 Landing Rd., Charles, MO 63333
(name & title of person who will store program records & location where records will be stored)
Access to these records will be limited to:
Heidi Pow, Program Committee and Donna Beck President
(list titles/positions of those who would be given access to records, e.g. program chairperson, chapter president)
Contact Person: Donna Back, RN, MSN, ANP / Email Address:
Home Phone: (555) 555 - 5565 / Work Phone: (444) 444 - 4445 ext. 235
Electronic signature is acceptable - please insert or type your name below:
Signature: Donna Back / Date: //2/2013
Signature indicates the education activity chairperson and planning committee assume full financial responsibility for providing this
CNE activity.
The applicant agrees to submit the following documents to the SUNA National Office within 30 days of completing the education activity: 1) Summary of Evaluations, and 2) Attendance Roster including complete address or email address. (Revised 2012)
DOCUMENTATION FORM I
II. Needs Assessment: Check all of the following strategies that were used to assess the learning needs of the target audience. This includes how learner input was considered in areas as content, location, and scheduling.
Content
Previous Program Evaluations / Quality Improvement Data / New Trends/Issues/Practices
Management Input / Interviews/Focus Groups / Professional Literature
Research Findings / Survey / Other:
Gap in Knowledge, skill, or practice that the educational activity is designed to improve or meet: IC is often misdiagnosed as a urinary track infection. On average there is a four year delay between the time first symptoms occur and the diagnosis is made
Purpose of the activity: The purpose of this activity is to enable the learner to identify the symptoms of IC and to outline the therapies that may be used to relieve the symptoms.
III. Target Audience: Check the audience for which this program is planned.
RN’s / LPNs/LVN’s / Technicians / Other: office staff
Practice setting of the above individuals (check all that apply):
Acute care / Long term care / Military / Office/clinic
Community / Independent practice / Other:
The above individuals provide interventions for:
Urologic Patients / Other:
IV. Presenters/Authors: Check how presenters were involved in the planning and evaluation of their presentations.
Planning: / Attended planning committee meeting / Discussion with planning committee member
Developed objectives / Developed content / Other:
Evaluation: / Informal feedback / Written evaluation / Post activity debriefing / Other:
Refer to the Documentation II form to complete V through X
DOCUMENTATION FORM I (continued)
XI. Evaluation: Check method(s) to be used in evaluating the education activity.
SUNA Evaluation Form / Self-Created Evaluation Tool / Pre/Posttest
Participant Interviews / Clinical Observation / Return Demonstration / Other:
Refer to the Disclosure Declaration Memorandum (DDM) and include the information listed below, along with specific details for each. The completed memorandum must be distributed to all attendees before the start of the educational activity
XII. Verification of Attendance - Check what learners must do to earn CNE certificate, then list on DDM
Must attend 100 %) of activity / Must complete and submit an evaluation of activity
Must complete and submit a posttest / Other:
XIII. Commercial Support for Activity? Yes No
If yes, you must also include a completed commercial support form and list all support on the DDM
XIV. Sponsorship for Activity? Yes No
If yes, you must also include a completed sponsorship agreement and list information on the DDM
XV. Co-Provider for Activity? Yes No
If yes, you must also include a completed co-provider agreement.
XVI. Vested / Conflict of Interest? Yes No If yes, list all vested/conflict of interest on the DDM
DOCUMENTATION FORM II
Submit one form per presenter/topic
Title: Interstitial Cystitis
This session addresses a gap in the following area: knowledge skill practice as evidenced by: Documentation that IC is often misdiagnosed aa a urinary track infection. On average there is a four year delay between the time first symptoms occur and the diagnosis is made.
V. ObjectivesList objectives in measurable, behavioral terms. (Objectives must be worded identically on the Evaluation form) / VI. Content (Topics)
In outline format, list each topic and the information that will be covered. / VII. Teaching Strategies
List all teaching strategies to be used. / VIII. Content Time Frame
List time frame for the content in minutes / IX. Description of the Activity
List the resources to be used: faculty names, clinical guidelines, peer reviewed journals, experts in the field
Objective #1
Discuss patient presentation of Intersticial Cystitis / Prevalence
Symptoms
Screening: PUFF question
K+ sensitivity
Physical Exam / Lecture
Case Studies
Discussion
Role Playing
Demonstrations
Q&A
Other (list below) / 20 min / Dr. Vern
Objective #2
Describe treatment options for interstitial cystitis / Triad of care
Elmiron
Amitrptyline
Cysto, distenstion, bladder biopsy, steroid injections
Program evaluation / (Enter only if strategies change) / 40 min
Objective #3 / (Enter only if strategies change)
(add additional rows if needed)
IX. Part II The content of this activity was selected from the following sources of best-available current evidence (check all that apply and/or complete “other”)
Clinical Guidelines Peer-Reviewed Journals/Literature Review
Current Regulations Current Research
Experts within the field other: http://www.nlm.nih.gov/medlineplus/interstitialcystitis.html; http://womenshealth.gov/publications/our-publications/fact-sheet/insterstitial Cystitis;http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001508/
X. Method/ Rationale for the number of contact hours to be awarded. State how the number of CNE’s was determined. Length of the live presentation in minutes, results of pilot test, or whatever method is used. 60 min of lecture= 1 CH
Biographical Data Form
Information for each person must be typed directly on a copy of this formName & Credentials / Daniel Vern MD
Home Address / 6 New Road
City / Louis / State / MO / Zip / 63333
Home Telephone / 555-555-5555
Employer Name & Department / Gynecological and Reconstructive Surgical Center
Business Address / 1234 South Road
City / Pitman / State / MO / Zip / 63333
Work Telephone / 111-123-1267 ext. 555 / Fax # / 555-123-7685
Preferred E-mail /
Social Security # (required if you are receiving an honorarium) / n/a--
Present Position (title and description): Uro-gyn surgeon
Education: List the degrees in the order of highest degree first
Degree
Awarded / Institution (must include name of institution, city, and state) / Major Area of Study / Year Degree Awarded
1. / Fellowship / Name: Massachusetts General Hospital
City: Boston State: MA / URO-GYN / 1997
2. / Residency / Name: Bay State
City: Boston State: MA / OB-GYN / 1991
Briefly describe your professional experience or area of expertise related to your particular role, e.g., planner, presenter, peer reviewer, administrator, etc.: I've present workshops on Interstitial Cystitis to medical and lay groups for over 12 years. I see a large number of IC patients in my practice.
Update 10/2012
SOCIETY OF UROLOGIC NURSES AND ASSOCIATES
FACULTY, PLANNER/CONTENT SPECIALIST
CONFLICT OF INTEREST STATEMENT
Planning Committee Presenter Planning Committee and Presenter
Each presenter and member of the planning committee must complete this form. All information must be typed. Make as many photocopies of this form as needed.Title of Activity / Interstital Cystitis
Name and Credentials / Daniel Vern MD
How were you involved in planning the content? (Check all that apply)
Worked with the planning committee to develop objectives / Developed/planned the content
Other (specify)
FACULTY, PLANNER/CONTENT SPECIALIST CONFLICT OF INTEREST STATEMENT
It is the responsibility of SUNA to insure balance, independence, objectivity, and scientific rigor in all CE activities. All faculties participating in the learning activity are expected to disclose to the learner any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the CE activity. Potential conflicts and financial relationships are provided in writing to the learner. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation. This policy is not intended to prevent a presenter with a potential conflict of interest from making a presentation. However, any potential conflict should be identified openly, with full disclosure, so that the learner may form their own judgments about the presentation. The learner will determine for themselves whether the presenter’s outside interests may reflect a possible bias in either the exposition or the conclusions presented. It does not assume that the existence of these interests or commitments necessarily implies bias or decreases the value of your participation. All learning activities are reviewed by the Nurse Planner to ensure a broad inclusiveness of the topic; that no trademark or branding information is present and that the presentation is unbiased.Presenters must abide by the following standards:
Faculty use of generic names will contribute to a balanced view of therapeutic options. If trade names are used, several companies should be identified rather than a single supporting company. No commercial branding or company logos can appear in the handouts or presentation.
DISCLOSURE DECLARATION
I, or a family member, have no actual or potential conflict of interest in relation to the presentation within the past 12 mos.I, or a family member, have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation within the past 12 months.
If yes, please answer the question below.
Affiliation / Financial Interest Self Other - Relationship:
Grant/Research Support:
Consultant/Presenter Bureau: Ortho
Major Stock Shareholder (not including mutual funds):
Advisory Board:
Other Financial or Material Support:
By signing this document, the presenter acknowledges that he/she will present in an unbiased manner.
Electronic signature is acceptable.
I attest that the information provided above is true.
Signature: D Vern Date: 12/01/2012
.
4/12
Evaluation FormOVERALL EVALUATION: To assist us in evaluating the effectiveness of this educational activity circle the appropriate rating.
Title of Activity: / Interstitial Cystitis
Date: / 3/20/2013
Strongly Strongly
Agree 5 4 3 2 1 Disagree1. / The individual session objectives were relevant to the overall purpose.
(Overall purpose: The purpose of this activity is to enable the learner to identify the symptoms of IC and to outline the therapies that may be used to relieve the symptoms.) / 5 4 3 2 1
2. / The content addressed important professional issues. / 5 4 3 2 1
3. / The program was well organized. / 5 4 3 2 1
4. / The physical facilities (hotel/meeting rooms) were appropriate. / 5 4 3 2 1
5. / There was an opportunity to network with my colleagues. / 5 4 3 2 1
6. / The content was balanced (free of commercial bias). / 5 4 3 2 1
5 4 3 2 1
List ideas for future topics, locations, and any comments about this activity.
PRESENTER EVALUATION: Evaluate the presenter and individual session objectives for only those sessions you attended.
Presenter: Dr. Vern
Session Title: Interstitial Cystitis
Strongly Strongly
Agree 5 4 3 2 1 DisagreeThe presenter was knowledgeable of the subject. / 5 4 3 2 1
The session was well organized / 5 4 3 2 1
The teaching strategies were appropriate. / 5 4 3 2 1
The following session objectives were met:
1. / Discuss patient presentation of interstitial cystitis / 5 4 3 2 1
2. / Review treatment options for interstitial cystitis / 5 4 3 2 1
3. / 5 4 3 2 1
Comments:
CERTIFICATE OF COMPLETION