CONTINUING NURSING EDUCATION GROUP (CNEG) APPROVER UNIT(formerly the Western MultiState Division/WMSD)

INDIVIDUAL EDUCATIONAL ACTIVITY APPLICATIONAlways download a new application from the website to ensure you have current version and requirements. Do not use saved file copies of this application as items may change to maintain ANCC compliance.

Directions: Only typed, electronic applications will be accepted. Please complete all questions on the application and include all required attachments. Attachments should be labeled and numbered in accordance with the application. Application must be submitted as one (1) collated Word or Adobe .pdf file to education@aznurse.org

Questions? Contact the CNEG office at education@aznurse.org or call 480.831.0404

DEMOGRAPHIC DATA Applicant/Organization Name:      

Applicant/Organization Address:      

Nurse Planner Name and credentials: Click here to enter text.

Note: The Nurse Planner must be a registered nurse who holds a current, unencumbered nursing license (or international equivalent) AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education activity.

Acceptable Example: Name, PhD, MSN, RN Name, PhD, BSN, RN-BC

Inappropriate Example: Name, PhD, RN as PhD might not be in nursing and RN does not indicate the academic level of the nursing degree)

Nurse Planner Email Address: Click here to enter text.

Nurse Planner Phone number: Click here to enter text.

Secondary Contact Person:      

Title/Position:      

Secondary Contact email address:      

Secondary Contact phone number:      

ACTIVITY INFORMATION ACTIVITY TITLE:      Enter below the number of contact hours offered and the total under review for this activity. For example, an activity that is 60 minutes in length, with three concurrent presentations is 3.0 contact hours to be reviewed and 1.0 contact hour offered that a participant can receive. NUMBER OF PARTICIPANT CONTACT HOURS OFFERED:       NUMBER OF CONTACT HOURS TO BE REVIEWED:      

ACTIVITY TYPE:☐Provider-directed, provider-paced: Live (in person or webinar)

Date of live activity: Click here to enter a date. Location of activity: Click or tap here to enter text.

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☐Provider-directed, learner-paced: Enduring material Start date of enduring material: Click here to enter a date. Expiration/end date of enduring material: Click here to enter a date.

☐Learner-directed, learner-paced: Enduring material Start date of enduring material: Click here to enter a date.

Expiration/end date of enduring material: Click here to enter a date.

☐Blended activity Date(s) of prework and/or post-activity work: Click here to enter a date. Date of live portion of activity: Click here to enter a date.

COMMERCIAL SUPPORT AMOUNT (IF APPLICABLE):Total Amount of Commercial Support       Please see Attachment 4 and include all agreement forms.

JOINTLY PROVIDED (IF APPLICABLE): ☐ No ☐ Yes Insert organization name(s)      

NARS Reporting Conversion Terms This section is included to assist with ANCC’s NARS data entry. Below is the list of terms and all information necessary to “open” and “close” an activity in the ANCC information tracking system. Please indicate the type of activity.

NARS Activity Type:☐ Course - A course is a live educational activity where the learner participates in person.

☐ Internet Live Course- An Internet live activity is an online course available via the Internet at a certain time on a certain date and is only available in real-time.

☐ Regularly Scheduled Series- A regularly scheduled series (RSS) as a course that is planned as a series with multiple, ongoing sessions.

☐ Journal Based CNE- A journal-based CNE activity includes the reading of an article (or adapted formats for special needs).

ELIGIBILITY VERIFICATION 1. Is this continuing education? Is this learning activity intended to build upon the education and experiential

bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to improve the health of the public and RNs' pursuit of their professional career goals?☐ If NO, STOP activity is not eligible for approval. ☐ YES, Continue to complete this application.

2. Identify Applicant's Organization Type: Choose an item. If other: Describe      

3. Is the Applicant Organization a commercial interest organization as defined by ANCC? ☐ NO, Continue to complete application. ☐ YES, STOP and contact CNEG to assess eligibility before completing this application.

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4. Is the applicant organization owned or controlled by a multi-focused organization that is a commercial interest organization by ANCC definition and produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients? ☐ NO, continue to complete application.☐ YES, STOP and contact CNEG to assess eligibility before completing this application.

5. The Nurse Planner is a registered nurse who holds a current, unencumbered nursing license (or international equivalent) AND holds a baccalaureate degree or higher in nursing (or international equivalent) AND is actively involved in planning, implementing and evaluating this continuing education activity.☐ NO – STOP The activity is ineligible to apply. Contact education@aznurse.org for questions. ☐ YES –continue to complete application.

STATEMENT OF UNDERSTANDING BY NURSE PLANNER On behalf of [Insert Name of Applicant Organization], I hereby attest that the information provided in this application is true, complete, and correct. I further attest, by my signature below that they will comply with all eligibility requirements and approval criteria throughout the approval period, and will notify the Continuing Nursing Education Group promptly, if, for any reason while this application is pending or during any approval period it does not maintain compliance.

I understand that any misstatement of material fact submitted on, with or in furtherance of this application for activity approval shall be sufficient cause for the Continuing Nursing Education Group to deny, suspend or terminate approval of this activity and to take other appropriate action against [Insert Name of Applicant Organization].

Electronic Signature (Required) Date: Click here to enter text.

Click here to enter text. Nurse Planner Name and Credentials

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EDUCATION NEEDS IDENTIFICATION AND ASSESSMENT OF LEARNER NEEDS

A. Description of the professional practice gap: (e.g. change in practice, problem in practice, opportunity for improvement)

Current State (What is currently happening)

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Desired State(What should be happening)

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Identified Gap(Difference between what is and should be happening)

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B. Evidence to validate the professional practice gap: (check all methods/types of data that apply) ☐ Survey data from stakeholders, target audience members, subject matter experts or similar☐ Input from stakeholders such as learners, managers, or subject matter experts☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement☐ Evaluation data from previous education activities☐ Trends in literature, law and/or health care☐ Trends in practice, treatment modalities and/or technology☐ Direct observation☐ Other—Describe:      

Please provide a brief summary of data gathered that validates the need for this activity (include statistics of information gathered to help to substantiate the need for this event):

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C. Educational need that underlies the professional practice gap (e.g. knowledge, skill and/or practices, if multiple, select one and type others in box) Choose an item.Choose an item.Additional Comments, if desired (not required)

EDUCATION DESIGN PROCESS

D. Description of the target audience. (You can select more than one target audience). 1. Choose an item. 2. Choose an item. 3. Choose an item. 4. Choose an item.

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E. Desired learning outcome(s) : - While a goal gives a general statement of your program's purpose, objectives are more concrete and specific in how the goal will be achieved. This is not about goals and objectives but about outcomes. Outcomes should reflect what is the expected as a result of your CE event. What will the learner’s outcome be as a result of participation in this activity? Clear articulation of learning outcomes serves as the foundation to evaluating the effectiveness of the teaching and learning process.). For example, “As a result of this activity, the learner will…”

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Area of impact (check all that apply): ☐ Nursing Professional Development☐ Patient Outcome☐ Other- Describe:      

F. Outcome Measure(s) : - A quantitative statement as to how the outcome will be measured to assess the impact of this educational activity in closing the identified gap. Focus on attendee behavior, use simple, specific action verbs, select appropriate assessment methods that are measurable, and state desired performance criteria that relate to the gap in knowledge, skill, and/or practice. For example, to measure a change in knowledge, a pre- and/or post-test may be used. To measure a change in skill and/or practice, return demonstrations, role-playing, case reviews, etc. may be utilized.

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G. Content of activity : A description of the content with supporting references or resources.

☐ See Educational Planning Table (required for all events over 3 hours) [see Attachment 1]

☐ OR describe here in a narrative style all the elements included when using the Educational Planning Table: session title(s) and presenter(s) names, the content outline, the teaching methods and learner engagement strategies, and allowable contact time calculation for the activity: Click here to enter text.

Content for this educational activity was chosen from: [include the reference]

☐ Information available from the following organization/web site (organization/web site must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content; examples – Agency for Healthcare Research and Quality, Centers for Disease Control, National Institutes of Health). List here:      

☐ Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years): List here:      

☐ Clinical guidelines (example - www.guidelines.gov): List here:      

☐ Expert resource (individual, organization, educational institution) (book, article, web site) List here:      

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☐ Presenter references: When the presenter(s) are the expert resource and source of the content's supporting references and resources the nurse planner informs them of the ANCC requirement to create their content from the best available current evidence or evidence based references and obtains a list of at minimum the top 1-2 references: List here or provide in a separate page attached to the end of the file:      

☐ All presenter’s references were not available at the time of this application. By checking this box the nurse planner attests that she has instructed the presenter(s) to create their content from the best available current evidence or evidence based references and acknowledges responsibility for obtaining a copy of their references to save in the activity file documentation.

☐ Textbook reference: List here:      

☐ Other: List here:      

H. Nurse Planner Assessment of Content for Commercial Interest* Relevance

*Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. (i.e. pharmaceuticals, supplements, botanicals, medical devices, and medical equipment products.

"Conflict of Interest exists when an individual is in a position to control or influence the content of an education activity and has a financial relationship with a commercial interest organization the products or services of which are pertinent to the content of the educational activity."

Describe the process utilized by the NP to determine if a conflict of interest exits for speakers and educational planning committee members. How is the NP assessing for potential COI? The response requires you to focus on how the NP addresses these 3 questions about the activity:

1. Does the activity include content related to a commercial entity’s products and/or services?2. Has the individual (or their significant other) had a financial relationship with a commercial entity

in the past 12 months?3. Is the individual on the planning committed in a position to control content?

As the NP assesses potential COI, the answer to ALL 3 of these questions must be “YES.” If the answers to all 3 questions above is YES, COI must be assessed, evaluated, and resolved. That process must be described in the box below. If ANY answer is “NO” then COI does not need to be assessed and you can skip to the “NO” option and select it.

For assistance, see Section F of the ANCC standards.

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☐ Yes, COI Forms RequiredThis educational activity includes content related to the products and/or services of a commercial interest entity by ANCC definition. A conflict of interest (COI) form is included in [Attachment 2] for each individual

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listed in Table I who has a financial relationship with a commercial interest entity relevant to this activity's content.

Examples: Stages of Breast Cancer and Current Treatment Modalities; Fall Prevention and Equipment

Solutions. Generally, clinical content is a yes here and all persons in a position to control content must be assessed for potential COI. Using generic terms instead of brand names for the product, services, or equipment does not exempt the content from potential for COI with a commercial interest organization that makes that type of product.

☐ No, COI Forms NOT RequiredThis educational activity does not include any content related to the products and/or services of a commercial interest entity so does not require COI forms for the planners or presenters.

Examples: Non- clinical content i.e. Staff Development Methods; Outcome Measures; Leadership Skills;

Documentation Excellence in the EMR; Clinical content without product related treatments discussions i.e. Understanding Hemodynamic Mechanisms; EKG Interpretation; Stages of Breast Cancer without treatment content.

Explain below why content is considered exempt for COI:

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Nurse Planner Signature:

I attest that I have reviewed the biographical information and actual/potential conflict of interest for each member of the planning committee members, content experts, content reviewers, authors, faculty, speakers, and presenters for the event and there are NO conflicts of interest to disclose.

Click or tap here to enter text. Click or tap to enter a date.

Typed or Electronic Signature: Name and Credentials (Required) Date

I. Individuals in a Position to Control Content Complete the table below listing each person in a position to control content of the educational activity. Include name, credentials, educational degrees(s), role in the activity, and any financial relationships with a commercial interest entity (define above in Item I) that is relevant to the content.

There must be at least two people --one Nurse Planner and one other planner to plan each educational activity. The Nurse Planner is knowledgeable of the CNE process and is responsible for adherence to the ANCC criteria AND hold a baccalaureate degree or higher in nursing (or international equivalent) AND be actively involved in planning, implementing and evaluating this continuing education activity. One planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert) and can also be the Nurse Planner or a Presenter who is on the Planning Committee. The individuals who fill the roles of Nurse Planner and Content Expert must be identified.

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Columns D, E, and F relate to the nurse planner's assessment of Conflict of Interest for the individuals in column A.

For questions about how to assess for conflict of interest for columns D, E, and F review the ANCC Standards specifically Section F.

A B C D E F G

Name of individual and credentials

Role(s) in activity

Nurse Planner (only one)

Content Expert Other Planner Presenter/Author

Planning committee member? (Yes/No)

Content Related to Commercial Interest Entity?(Yes/No)

Commercial interest relationship?(Yes/No)

If yes in E Name of Commercial Interest and nature of relationship

If yes in C, D, AND E, Attached COI form(Yes or n/a)

Example: Jane Smith, BSN, RN

Nurse Planner Yes No n/a n/a

Example: Sue Brown, PhD, RN

Content Expert Yes No n/a n/a

Example: Ida Row, MSN, RN Other Planner Yes No n/a n/a

Example: John Doe, MD Presenter No Yes Pfizer Speakers Bureau

Yes

Add rows as neededA.B. Describe how it was determined that the Nurse Planner and Content Experts are qualified for these roles: C. Provide information about NP expertise/education in adult education or adult learning and ANCC credentialing criteria.

Describe professional experience or areas of expertise, which contribute to content expertise for this activity. May include educational background, professional/practice experience, and publications. (Provide detailed information supporting why this person has been deemed an expert in the field.

J. Learner engagement strategies : ☐ See Educational Planning Table OR check below which strategies will be used:

☐ Integrating opportunities for dialogue or question/answer☐ Including time for self-check or reflection☐ Audience response system☐ Analyzing case studies☐ Providing opportunities for problem-based learning☐ Pre/Post Test☐ Other:      

K. Contact Hour Calculation Contact hours must be determined in a logical and defensible manner, and awarded to participants for those portions of the educational activity devoted to learning and evaluation. One contact hour = 60 minutes. Fractions

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or portions of the 60-minute hour can be awarded. For example, 135 minutes equals 2.25 contact hours. Do not round up (e.g. 2.758 should be 2.75 or 2.7, not 2.8).

Time for registration, introductions, opening announcements, breaks, meals, business meetings and viewing of exhibits are NOT included in the calculation of contact hours. Viewing of poster sessions and evaluations may be included but require a defensible method for calculations.

1. If activity is more than 3 hours (from registration to closing) attach an educational planning table or a detailed agenda (Attachment 1) for the entire educational activity.

2. Enter the maximum number of contact hours a participant could earn for this activity: Click or tap here to enter text.

3. Identify the method used to calculate the number of contact hours awarded to each participant:

☐ Total number of eligible minutes for each session attended divided by 60 ☐ Pilot study – average time for completion of activity by testers☐ Historical data – compared this activity to a similar existing enduring material activity☐ Professional opinion based on complexity of content and delivery method☐ Mergener Formula used for text content

Number of Words Click or tap here to enter text.Number of Questions Click or tap here to enter text.Degree of Difficulty Click or tap here to enter text.

☐ Other (Describe): Click or tap here to enter text.

L. Criteria for Awarding Contact Hours Criteria for awarding contact hours for live and enduring material activities include:

(Check all that apply)

☐ Attendance for a specified period of time required. ☐ 100% attendance for entire Event ☐ Miss no more than 10 minutes of Event ☐ Other: Describe here:Click or tap here to enter text.

☐ Contact hours awarded for actual hours attended (requires tracking of attendance per conference day, per plenary and breakout sessions. This option allows for partial credit.)

☐ Completion/submission of evaluation form ☐ Successful completion of a post-test (e.g., attendee must score Click or tap here to enter text.% or higher)☐ Successful completion of a return demonstration ☐ Other - Describe: Click or tap here to enter text.

M. Description of evaluation method: - How will change in knowledge, skills, and/or practice be evaluated at the end of this activity? Refer to identified practice gap and educational need – evaluation must occur at the level of need identified in “C” above.

A clearly defined evaluation method includes learner input used to assess the effectiveness of the educational activity. The evaluation components and method of evaluation should relate to the desired learning outcome of the educational activity. Evaluation methods may include both short term and long term. ( Sample Participant Evaluation Form)

Evaluation methods may include both short term and long term.

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Short-term evaluation options (How will this information be gathered and results analyzed at the end of the CE event?):☐ Participant evaluation with self-report Intent to change practice☐ Active participation in learning activity☐ Post-test☐ Return demonstration☐ Case study analysis☐ Role-play☐ Other – Describe:      

Long-term evaluation options (This is not required but if long term evaluation is to be conducted describe how the information will be gathered and results analyzed to determine impact of the CE event over time at a specific interval after the event has been completed?):

☐ Self-reported change in practice☐ Change in quality outcome measure☐ Return on Investment (ROI)☐ Observation of performance☐ Other – Describe:      

Describe below the process that will be followed for evaluating this activity. This must include the process for short term evaluation. If long term evaluation will be conducted, describe the process that you will follow.

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POST ACTIVITY DOCUMENTATION RECOMMENDATIONS N. Summative Evaluation

Documentation after the event summarizing the findings from the participant evaluations and determination by the nurse planner of need for any follow up action steps.

Documentation after the event must summarize: total number of participants contact hours earned by each participant pertinent findings from the participant feedback, comments, and suggestions for future topics documentation by the nurse planner of need for any follow up action steps and actions taken

This summation is maintained in your activity file.

O. Record Keeping Requirements ☐ By checking this box the applicant acknowledges responsibility for maintaining documentation for each educational activity in a secure, confidential, and retrievable manner for six years from the last date the activity was provided. Learners must be able to contact the applicant organization if verification of attendance or a replacement certificate of completion is needed. The Nurse Planner is responsible for assuring that an adequate recordkeeping system is in place. The recordkeeping files must include all of the ANCC required documentation. See Recordkeeping Checklist.

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ATTACHMENTS

Please provide evidence of the following by including these Attachments:

Attachment 1 Educational Activity Planning Table with full agenda timeline from registration to closing if event is over 3 hours.

Attachment 2 Conflict of interest documentation from all individuals in a position to control content (e.g. planners, presenters, faculty, authors, and/or content reviewers) and resolution if applicable OR a statement that COI documentation is not required because the content of the activity has no relationship to products or services of a commercial entity (consumed by or used on patients)

Attachment 3 Documentation of completion and/or certificate.

Attachment 4 Commercial Support Agreement with signature and date (if applicable)

Attachment 5 Disclosures/ Evidence of required information provided to learners prior to start of the activity (ensure there is consistency throughout the document):

1. Activity approval statement as issued by the accredited approver2. Criteria for successful completion in order to receive contact hours3. Presence or absence of conflicts of interest for all individuals in a position to

control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers) If COI is present, disclosure must include name of person, type of relationship, and name of commercial entity.

4. Commercial support (if applicable)5. Expiration date (enduring materials only)6. Name(s) of Joint Provider(s) (if applicable)7. NOTE: (Materials associated with the activity (marketing materials, advertising,

agendas, and certificates of completion) must clearly indicate the Provider awarding contact hours and responsible for adherence to ANCC criteria)

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Attachment 1Insert Educational Activity Planning Table

[Applicant Organization Name]Educational Planning Table and Agenda

Title of Activity: Learning Outcome(s): This should match what you indicated in section E above

TIME ALLOTMENT*

LIST EACH SESSION TITLE & PRESENTERCONTENT (Topics)

Provide an outline of the contentTEACHING METHODS/LEARNER

ENGAGEMENT STRATEGIESStart Time

Stop Time

Total Minutes

15Introduction

60TitlePresenter Name

30TitlePresenter Name

15Break

45TitlePresenter Name

45TitlePresenter Name

60Lunch

30TitlePresenter Name

30TitlePresenter Name

30TitlePresenter Name

15Closing and evaluation

Add rows as needed

Total Agenda Minutes

375 Add all minutes including NON-CE content minutes, introductions, breaks and meals

Total Contact** Minutes

285 Total minutes ___375______minus total NON-CE minutes_90_____divided by 60 = _____4.75___contact hours

*Include introductions, breaks, & meals and non CE content time but do not count in total contact minutes**Time spent evaluating the learning activity may be included in the contact minutes when calculating contact hours.

Attachment 2Attach all required Conflict Interest Forms

(If you checked NO in Section H, COI forms are not required)

Conflict of Interest Form2015 ANCC Criteria

If it has been determined by the NP that no conflict of interest exists for this activity, COI documentation is not required because the content of the activity has no relationship to products or services of a commercial entity (consumed by or used on patients). The process for determination should be described in section H in the application.

If there is potential for a COI for this event, a COI form must be competed for all presenters and members on the educational planning committee, including a COI for the Nurse Planner that has been reviewed by another planning committee member.

Title of Educational Activity:      Educational Activity Date:      

Role(s) in Educational Activity: (Check all that apply) ☐ Nurse Planner ☐ Content Expert ☐ Faculty/Presenter/Author☐ Other Planner ☐ Other, Describe     

Section 1: Demographic Data

Name with Credentials/Degrees: Click or tap here to enter text.If RN, check all Nursing Degree(s) held:       AD       Diploma       BSN       Masters       Doctorate

Current Employer Position/TitlePhone number:Email Address:Mailing Address

City, State and Zip Code

Section 2: Conflict of InterestThe potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity.

*Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. (Please reference content integrity document for further clarity.)

All individuals who have the ability to control or influence the content of an educational activity must disclose all relevant relationships** with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. All information disclosed must be shared with the participants/learners prior to the start of the educational activity.

**Relevant relationships, as defined by ANCC, are relationships with a commercial interest if the products or services of the commercial interest are related to the content of the educational activity.

Relationships with any commercial interest of the individual’s spouse/partner may be relevant relationships and must be reported, evaluated, and resolved.

Evidence of a relevant relationship with a commercial interest may include but is not limited to receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (stock and stock options, excluding diversified mutual funds), grants, contracts, or other financial benefit directly or indirectly from the commercial interest.

Financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest.

Is there an actual, potential or perceived conflict of interest for yourself or spouse/partner?

      Yes       No

If yes, please complete the table below for all actual, potential or perceived conflicts of interest.** Check all that apply:

Category Description

Salary

Royalty

Stock

Speakers Bureau

Consultant

Other**All conflicts of interest, including potential ones, must be resolved with the nurse planner prior to the planning,

implementation, or evaluation of the continuing nursing education activity.

Section 3: Statement of Understanding

Completion of the line below serves as the electronic signature of the individual completing this Conflict of Interest Form and attests to the accuracy of the information given above.

Click or tap here to enter text. Click or tap to enter a date.Typed or Electronic Signature: Name and Credentials (Required) Date

Section 4: Conflict Resolution (to be completed by Nurse Planner)Or document separately

Procedures used to resolve conflict of interest or potential bias if applicable for this activity: (Check all that apply)

     Not applicable since no conflict of interest.

     Removed individual with conflict of interest from participating in all parts of the educational activity.     Revised the role of the individual with conflict of interest so that the relationship is no longer relevant to the

educational activity.     Not awarding contact hours for a portion or all of the educational activity.      Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in

presentation, evidence-based content or other indicators of integrity, and absence of bias, AND monitoring the educational activity to evaluate for commercial bias in the presentation.

     Undertaking review of the educational activity by a content reviewer to evaluate for potential bias, balance in presentation, evidence-based content or other indicators of integrity, and absence of bias, AND reviewing participant feedback to evaluate for commercial bias in the activity.

     Other - Describe:     

Nurse Planner Signature(*If this form is for the activity Nurse Planner, an individual other than the Nurse Planner must review and sign

below).Completion of the line below serves as the electronic signature of the Nurse Planner reviewing the content of this COI Form. Click or tap here to enter text. Click or tap to enter a date.

Typed or Electronic Signature: Name and Credentials (Required) Date

Attachment 3 Attach a sample of your Certificate of Completion

Your sample certificate must include these ANCC required elements:

1. Name and address of the provider of the educational activity (web address is acceptable)2. Participant name 3. Title and date of the educational activity4. Number of contact hours awarded and CNEG Approval ID number5. Approval statement:

This continuing nursing education activity was approved by the Continuing Nursing Education Group, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Example Certificate of Completion

Attachment 4Attach any Commercial Support Agreement(s) if applicable

May use below or the Commercial Interest Organization's preferred agreement.

Example Commercial Support Agreement

Attachment 5Insert here a copy of the disclosures you are providing to learners prior to start of the activity or use this template. Your disclosures must include items 1-4 and 5-6 if applicable. Remove verbiage that does not apply. Complete the Action area and remove 5-6 if they do not apply.

DISCLOSURES HANDOUT/ FIRST SLIDE FOR PARTICIPANTS

If using verbal disclosures, a written attestation form must be completed and signed by an audience member (not a nurse planner or program facilitator) indicating what disclosures were provided.

Activity Title:Activity Date:

Disclosure Action1) Approval Statement This continuing nursing education activity was approved by the Continuing

Nursing Education Group, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

2) Criteria for Successful Completion

Insert participant requirements to receive contact hours.

3) Conflicts of Interest

Presence or absence of conflicts of interest for all individuals in a position to control content (e.g. the Planning Committee, presenters, faculty, authors, and content reviewers)

MUST CHOOSE ONE and delete the others:

This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest.

ORNo individuals in a position to control content for this activity has any relevant financial relationships to declare.

ORThe following individuals in a position to control content for this activity declare they have a commercial interest relationship relevant to the content of this activity and it has been resolved with the nurse planner.

_____NAME_____________(insert the type of relevant financial relationship). Examples:Ann Jones, RN is on the Speaker's Bureau for XYZ Company.Ralph Emerson owns stock in XYZ Company

4) Commercial Support MUST CHOOSE ONE and delete the other:

(Insert Name of Commercial Interest) provided financial or in-kind support for this activity and signed a commercial support agreement:

ORThere is no commercial support being received for this event.

5) Expiration date for Enduring Materials if applicable

Origination Date: insert the dateExpiration Date: insert the date (2 years after approval)

6) Joint Provider(s) if applicable

This activity is being jointly provided by [Insert Applicant’s Organization Name] and [insert Joint Provider Organization's name(s)].