ADDENDUM

for an

INDEPENDENT OR SELF STUDY ACTIVITY

NOTE:

  • This four-paged section must be completed if the activity is an independent or self study.
  • Please read the corresponding criteria in the INAInstruction Manual for Approval of an Individual Educational Activity.

Type of Media
If an independent or self study, state the type of media (e.g., internet/Web, pod casts, printed materials via US mail):
Communication
Describe the method the learner is to use to communicate with the providing organization regarding this self study.
Evaluation
1.The method(s) to be used to evaluate the activity is as follows.
Evaluation form (Required at all events)
Pre and/or Post-Test (Optional)
Direct observation of skill performance (Optional)
Structured interview (Optional)
Attitude scale (Optional)
Other. Please describe:
2.The evaluation data will be used to improve the activity as follows:
Revise future presentations of this activity
Create new programs
Discontinue the activity
Decide whether or not to change the presenters or content specialists
Other. Please describe:
3.The category of evaluation to be used for this activity and completed by the end of the learning experience is as
follows: (Type an X in the white area for all that apply) Note: The documentation must support the identified category.
Learner satisfaction(simplest example, standard evaluation form)
Knowledge enhancement
Skill and attitude
Change in practice or performance
Relationship of practice to quality of service
Other. Please describe:
4a. Do you plan to include the following advanced categories of evaluation?
No
(If no, please proceed to 5 below)
Yes
(If yes, please complete 4b below)
4b.The data will be collected for advanced categories of evaluation as follows: (Type an X in the white area for all that apply)
Change in practice/performance
(usually done 3 months after learning; e.g. self-report of change, observation of performance audits, etc.)
Relationship of the practice change to quality of service
(most complex, usually done 6 months after the event; review final outcomes)
5. Attach a copy of the evaluation tool for an independent or self study to be used at the upcoming educational
activity.

The evaluation tool must include at a minimum for the learners’ assessment:

  1. Learners’ achievement of all of the activity’s objectives.
    Explanation: (i) The learner objectives on the three or five-column form must be well represented on the evaluation tool. (ii) If this is a large activity, global learner objectives may be used as a substitute when there are numerous individual learner objectives on the Educational Activity Overview form.
  2. Effectiveness of the learning materials. (e.g., videotapes, articles, Website content and quizzes)
  3. Ease of use of the learning materials.
  4. How long did it take to complete the independent study?
  5. Include a question regarding content integrity, e.g., “Was the content presented without bias of any commercial product or drug?” Note: This question may be reworded on the Evaluation form; however, the purpose of the question must be maintained.
  6. Include aquestion regarding the disclosure of the presence or absence of planners’ and presenters’ conflict of interest.

Time Frames/Contact Hour Calculation

Assign an appropriate amount of time to the content on the three or five-column form(s) which is consistent with the respective objectives/content outlines. Please refer to the Educational Activity Overview form.

  1. The method used to estimate the amount of time necessary to complete the entire independent study activity and accurately calculate the contact hours is as follows. (Check all that apply):

Pilot Study (Note: Contact hours may be awarded to pilot testers.)
Peer Review
Historical Data
Complexity of content and data
Other. Please describe:
2. Provide a description that supports the rationale used to determine the independent study’s number of contact
hours.
For example, if using historical data, describe the data from the previous presentation(s) and how it supports the contact hours. If using a pilot study, describe the results of the pilot study including the number of pilot testers. If using a peer review, specifically describe the results of review and why it is favorable to a pilot study.
Effectiveness of Independent or Self Study

The study or review to determine the effectiveness of the study must be completed prior to the application being submitted to the INA

Approver Unit.

  1. Describe the method for determining the overall effectiveness of the independent study was determined.

2.Describe the results of the evaluation and the changes made to the activity before it is made available to the learners.
Disclosure of Expiration Date for Awarding Contact Hours
  1. The learners will be informed of the expiration date for awarding contact hours for the enduring material of this activity by: (Type an X in the white area for all that apply)

Information provided on advertising materials (Attach copy if selected)
Information on direction/guideline page (Attach copy if selected)
Other. Please describe:
2.Attach a copy of the document that discloses the expiration date for awarding contact hours.

REMINDER:

Application for Approval of an IndividualEducational Activity

The other sections of the criteria must also be completed in the main application.

OR

Application for Provider Approval

The other sections of the criteria must also be completed in the Approved Providers’ Main Documentation form.

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Revised 11/09

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