LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Individual Educational Activity Application
The LSNA Approver Unit is accredited as an approver of continuing nursing education (CNE) by the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation (COA) and adheres to the criteria established by the ANCC-COA.
IEA Applicants of continuing nursing education (CNE) who participate in the approval process are expected to document compliance with all Provider and Educational Design Criteria.
Read all instructions carefully, if you have any questions or concerns contact CNE Coordinator.
DIRECTIONS:
ALL SUBMISSIONS are required to be, this includes later revisions as well,...
· On the current forms, which can be found at www.lsna.org
· Done electronically & typed; mailed, faxed, and handwritten entries will NO longer be accepted.
· Check Boxes
· Highlight (yellow) can be used for making a selection as well.
· In WORD or PDF (For purpose of this review only: PowerPoint and Excel file examples need to be converted to PDF)
· Clearly labeled and…
o Emailed to
§ Subject Line: Title of Activity – APPLICATION
OR
o Mailed to LSNA on a flash drive or cd (see below under PAYMENT for address)
APPLICATION:
1. Required to be received at least 60 DAYS before the date of the activity fully completed.
· (no retroactive approval is ever allowed)
See payment form for late fees (20 DAYS BEFORE WILL NOT BE ACCEPTED).
· If you are not certain of the date, state when it might be scheduled in the future
Example: To be scheduled “once approval received” or “after mm/dd/yy [In future]”
Remember to notify LSNA in writing once the date is scheduled.
2. Some of the information will be typed directly on the form; others will be documents you attach. Attached information is required to be clearly labeled and titled in accordance with the outline, divided clearly, and numbered in sequence.
· If more space is needed than provided, in any section, clearly identify where to find continuation.
3. Live vs. Enduring Activities – No longer have separate forms.
4. Documents and instructions related to the application are located in the Samples and Resources sections on the website.
If the activity is approved, it can be presented as often as desired during the two-year approval period
as stated on the approval letter unless substantial changes are made.
CHANGES:
1. A speaker, nurse planner, or planning committee member can be changed after approval but not the presentation content.
a. Submit an updated BIO & Conflict Form for the nurse planner or planning committee member FOR REVIEW.
2. A new sponsor can be submitted at any time (even after approval) with the correct documents to the CNE coordinator for review, before the IEA is given.
PAYMENT:
1. The IEA Payment Form has the fees for the review process. Applications will not be considered complete unless payment (with form) has been received; must be with but separate from the application.
2. Payment is for the review process ONLY; once the process has started no refunds will be given for denial or withdrawal.
3. Checks (if paying by) - mail to LSNA with a copy of the Payment Form for reference.
a. Do not forget to factor in the time it will take for YOUR organization to process payment and send.
Payable: LSNA
Mail to: 543 Spanish Town Rd
Baton Rouge, LA 70802
It is suggested the applicant put the Nurse Peer Review Leader email on the safe sender list:
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
IEA APPLICATION CHECKLIST
A completed application includes the following:
☐1 electronic copy of the completed Individual Educational Activity Application Packet
☐1 electronic copy of the completed PAYMENT FORM (with but separate from application)
Individual Educational Activity Application Packet includes:
☐IEA Application (THIS FORM)
☐Attachment 01: Gap Analysis Worksheet
☐Attachment 02: Educational Planning Table
(DO NOT SEND SLIDES OR HANDOUTS)
☐Attachment 03: Evaluation Form
☐Attachment 04: Biographical & Conflict of Interest Form (for Nurse Planner Content Expert)
(DO NOT SEND CVS OR RESUMES)
☐ Attachment 05: Agenda
☐Attachment 06: Advertising materials
☐Attachment 07: Commercial Support Agreement(s)*
☐Attachment 08: Disclosure Communication
☐Attachment 09: Certificate of Successful Completion
☐Attachment 10: Commercial Interest Addendum*(If necessary)
*This form may not be applicable to your application.
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Applicant Eligibility Verification
Applicants interested in submitting an individual educational activity for approval must complete the
Eligibility Verification Form and meet all Eligibility Requirements. Verification forms received from applicants that do not meet Eligibility Requirements will be rejected without substantive review.
Section 1: Eligibility
Applicant/Organization:
Name:Email: / Web Address:
Address/City : / State: / ZIP:
Identify Organization Type:
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
☐Constituent Member Association of ANA
☐College or University
☐Healthcare Facility (includes home health, hospice, etc.)
☐Health Related Organization
☐Multidisciplinary Education Group
☐Specialty Nursing Organization
☐Other
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
If other: Describe Click here to describe
Primary Contact Person:
Name: / Title/Position:Email: / Phone: / EX:
A. Has the applicant ever been denied accreditation by ANCC or had its accreditation status suspended or revoked? ☐Yes ☐No
If yes, please provide the following information: Action: ☐Denial ☐ Suspension ☐ Revocation
Date: Click here to enter a date.
Brief description: Click here to Describe
B. Has the applicant ever had approval denied, suspended, or revoked for an Individual Educational Activity or Approved Provider application by any ANCC Accredited Approver? ☐Yes ☐No
If yes, please provide the following information: Action: ☐Denial ☐ Suspension ☐ Revocation
Name of Organization Issuing: Click here to enter a date. Date: Click here to enter a date.
Brief description: Click here to Describe
C. A currently licensed registered nurse, with a baccalaureate degree or higher in nursing, is actively involved as the Nurse Planner in the planning, implementing, and evaluation process of this continuing education activity: ☐Yes ☐No
List the name and credentials of the nurse(s) involved/responsible for this educational activity:
Nurse Planner Name & Credentials / Email / Nursing License #/State(tab in last box for more space)
Section 2: Commercial Interest
The following section is intended to collect information about the applicant's corporate structure.
A. ☐ An "X" on this line identifies the applicant type as automatically exempt from ANCC’s definition of a commercial interest.
Identify the applicant's exemption type below:
☐Blood banks☐Constituent Member Associations
☐Diagnostic laboratories
☐Federal Nursing Services
☐For-profit & not for profit hospitals
☐ For-profit & not for profit nursing homes
☐For profit & not for profit rehabilitation centers
☐Group medical practices
☐Government organizations / ☐Health insurance providers
☐Liability insurance providers
☐National nurses’ organizations
(based outside the United States)
☐Non-health care related companies
☐Specialty Nursing Organizations
☐A single-focused organization
(exists for the single purpose of providing CNE)
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
501c applicants are not automatically exempt.
The ANCC Accreditation Program requires 501c applicants to be screened for eligibility.
If you checked the box above, you have completed this questionnaire, proceed to Section 4.
**Only complete section B if applicant organization is NOT exempt**
B. An "X" on this line identifies the applicant as not exempt from the ANCC Accreditation Program’s definition of a commercial interest.
The following questions must be answered to properly assess the applicant's eligibility:
1. Does the applicant produce, market, re-sell, or distribute health care goods / services consumed by, or used on, patients?
☐Yes If yes, the applicant is not eligible for approval of Individual Educational Activities.
☐No If no, complete the next bulleted question
2. Is the applicant owned or controlled by a multi-focused organization (MFO*) that produces, markets, re-sells, or distributes health care goods / services consumed by, or used on, patients?
☐Yes If yes, complete the next bulleted question
☐No If no, this section of the questionnaire is complete, proceed to Section 4.
3. Is the applicant a separate and distinct entity from the MFO*?
☐Yes If yes, continue to section 3
☐No If no, the applicant is not a separate and distinct entity from the MFO* then the applicant is not eligible for approval of Individual Education Activities.
* Multi-Focused Organization (MFO) is an organization that exists for more than providing continuing nursing education.
Section 3: Commercial Interest Evaluation
A. Does the MFO that owns the applicant have a 501-C Non-profit Status?
☐Yes
☐No If no, complete section B.
If yes, does the company that owns the applicant advocate for a commercial interest (as defined by the ANCC Accreditation Program?)
☐Yes If yes, or not sure, please describe the relationship the company that the applicant has with a commercial interest and the types of work the company that owns the applicant does for or on behalf of a commercial interest that might be considered advocacy. Click here to enter text.
☐No Commercial Interest
B. Is any component of the MFO an entity that produces, markets, re-sells, or distributes health care goods / services consumed by, or used on, patients?
☐Yes If yes, please describe the health care good / service consumed by, or used on, patients and the role of the entity in producing, marketing, re-selling or distributing those healthcare goods / services.
Click here to enter text.
☐No If no, this section of the questionnaire is complete, proceed to Section 4.
If yes, please complete and submit the
☐ Commercial Interest Addendum Template (Attachment Ten)
If you have any questions about your organizations eligibility
STOP HERE
Contact the Approver Unit
Individual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Section 4: Statement of Understanding
Does The Planned Activity Meet the Definition of Continuing Nursing Education?
A. Does the planned educational activity meet ALL of the following requirements?
· Content must meet the definition of continuing nursing education[1]
· Content must enable the learner to acquire or improve, knowledge or skills, beyond basic knowledge
· Content must enhance professional development or performance of the nurse
· Content must be evidenced-based or based on the best available evidence
· Activity must be at least 30 minutes in length
☐ YES Please continue to Nurse Planner Attestation.
☐ NO This educational activity is not eligible for review.
B. Nurse Planner Attestation (enter organization name):
On behalf of Click here to enter text, I hereby attest the information provided on and with this application is true, complete, and correct. I further attest, by my signature below that Click here to enter text will comply with all eligibility requirements and approval criteria throughout the approval period, and that Click here to enter text will notify the LSNA promptly, if, for any reason while this application is pending or during any approval period, Click here to enter text does not maintain compliance.
I understand any misstatement of material fact submitted on, with, or in furtherance of this application for activity approval shall be sufficient cause for the LSNA to deny, suspend, or terminate approval of this activity and to take other appropriate action against Click here to enter text.
☐ Electronic Signature: An ‘X’ serves as the electronic signature of the individual completing this form, attests to the accuracy of the information given above
☐ and I hereby give LSNA permission to release activity information on the website.
Nurse Planner Name and Credentials (required) / DateIndividual Activity Application, 2015 criteria, 12/2016 Page 2 of 16
LOUISIANA STATE NURSES ASSOCIATION is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Demographic Data:
Contact Person (person filling out the forms):
Name: / Title/Position:Email: / Phone: / EX:
Organization:
Address/City: / State: / ZIP:
Activity:
Title:Location: / # Contact Hours:
Address/City: / State: / ZIP:
Activity Type:
☐ / Provider-directed, PROVIDER-paced: Live (in person or webinar)DATE of LIVE activity:
☐ / Provider-directed, LEARNER-paced: Enduring material (no more than 2 years)
Start DATE Enduring Material:
End DATE Enduring Material:
NURSE PLANNER for this activity:
Name: / Credentials:Email: / Phone: / EX:
Address/City: / State: / ZIP:
Educational Design Processes:
A. Description of the professional practice gap:
Identify the gap(s) (difference between current state and desired state) in knowledge, skills, or practice revealed by the needs assessment, which the activity was designed to address (i.e. change in practice, problem in practice, and opportunity for improvement).
The planning committee should:
1. Use information from the needs assessment to identify the current level of knowledge, skill, or practice of the target audience.
2. Then determine the difference between the prospective participant’s current level of knowledge, skill, or practice and where it should be; this difference is the ‘problem in practice’ or ‘gap’.