APPLICATION FOR APPROVAL OF A CONTINUING EDUCATION ACTIVITY
Continuing Health Professional Education • 2500 North State Street • Jackson, Mississippi 39216-4505
Telephone: (601) 934-1300 • FAX: (601) 984-1309
MUST BE TYPED (Form Field) and returned with attachments
The following criteria apply for all continuing education activities considered for sponsorship by the University of Mississippi
1. The University of Mississippi Medical Center does not sponsor or jointly sponsor continuing education activities with commercial
2. The Course Director/Coordinator must be a University of Mississippi Medical Center faculty member with expertise in the
subject area of this activity, and he or she along with a UMMC Division of Continuing Health Professional Education (CHPE)
program administrator must actively participate in program planning and implementation.
3. This application must be completed in detail and submitted to the University of Mississippi Medical Center (UMMC) Division of
Continuing Health Professional Education five months prior to the proposed program date for a state or regional meeting and
eight months prior to the program date for a national meeting. Any deviation from this timetable must be approved by the UMMC
Continuing Education office.
4. No publicity may be printed or mailed regarding a UMMC-sponsored Continuing Education activity until the activity and all
printed materials advertising the activity have been reviewed and approved by the UMMC Division of Continuing Health
5. In accordance with ACCME Standards for Commercial Support for physician AMA PRA Category 1 credit(s)TM, ADA CERP
Standard V for dental credit, ACPE for pharmacy credit, and MNF accredited approver by ANCC for nursing credit, all persons
involved in control of content are required to complete and sign a disclosure form. This includes speakers, directors, course
directors, planners, moderators, content validation reviewers and other personnel who have control over content. These forms
should be submitted with this application. See Part F
Activity Location (City, State, Facility):
UMMC Faculty Course Director/Nursing Program Coordinator:
Tel. No. Fax No.
Name(s) of Joint Sponsor if applicable: (UMMC does not sponsor or jointly sponsor continuing education activities with
Target audience: Check specialty group(s) and indicate expected number of attendees.
Dentists: Nurses: NP RN LPN Pharmacists:
Physicians by specialty (i.e. pediatrics):
Health Related Professions (list): Others: (list):
List any special background requirement(s) of the target audience.
Maximum number expected to attend:
Credit being applied for through CHPE:
*Non-UMMC accrediting bodies – additional time required to apply for credit.
*Certified Case Managers: CCMC credit
Certified Athletic Trainers: BOC credit
*Dentists: Mississippi Dental Association
*Dietitians: CDR CPEUs
*Nuclear Medicine Technologists: VOICE Credit
Nurses: MNF/ANCC (additional pages required – attached)
*Ophthalmology Allied Health Personnel: JCAHPO
Physicians: AMA PRA Category 1 Credit(s) TM
Social Workers: NASW, Mississippi Chapter
*Other: Please identify association name, contact person name, address and telephone number:
From what other professional agencies/organizations will credit approval be requested? Who will be responsible for applying
for these credit approvals?
Number of CE hours requested:
For CHPE office use only
Number of credits:
PART A – NEEDS ASSESSMENT
How were the educational needs of the target audience for this activity identified? Attach notes from your file, survey results,
results from review of patient care audits, etc., that show a need for the activity. A check mark in the appropriate space below is
not adequate documentation. State the need(s) that was identified and the process that was used to identify the need(s).
Documentation is required to show that the needs assessment method went beyond the faculty course director’s own perception of
a need for the activity.
Check all that apply and attach appropriate documentation
Survey of Target Audience Literature Search
Evaluation of previous CE Activities Epidemiology Reports
Quality Assurance/Peer Review Request From Target Audience
Expert focus group in subject area of activity Changes in regulations
Changes in Patient population or care requirements Problem or issue related to nursing practice
Other Method (Please specify method used)
Label Attachment A
PART B – PURPOSE AND LEARNING OBJECTIVES
1. Briefly state the purpose of this activity and the target audience. Limited to two sentences. (This statement should be used in
advertising materials and will be used as part of the UMMC activity evaluation tool.)
2. State what the target audience should be able to do as a result of attending this activity by providing a separate
learning objective for each lecture using an action-oriented verb. Do not use generalities. The educational objectives
should designate the knowledge level or performance skill the participant can expect to attain by attending the
meeting. Objectives should read “Upon completion of this topic, the participant should be able to…”
See Part C1/B below
PART C – PROGRAM DESIGN AND IMPLEMENTATION
1. Agenda - The attached C1/B form includes the proposed program agenda identifying dates, times, topics, objectives, content,
speakers, teaching methods and audiovisual. Complete Attachment C1/B
Note: Each topic should have at least one behavioral objective with the content identified.
2. Speakers - The attached C2 form includes all speaker information. Attach a current curriculum vitae for each speaker.
Payment of reasonable consulting fees and reimbursement of out-of-pocket expenses for faculty is customary and proper for
non-UMMC. Complete Attachment C2
3. Planners – The attached C3 form includes all planner information. Attach a current curriculum vitae for each planner. All
planners will be kept up-to-date on the requirements for adhering to ACCME, ACPE, and ANCC criteria via email and
Complete Attachment C3
4. Describe how the University of Mississippi Medical Center faculty member will actively participate in the planning of this
PART D – EVALUATION
Evaluation information is necessary to determine whether or not continuing education (CE) activities meet the stated program impact
and the University’s overall CE mission. Which of the following was the activity designed to impact:
Competence, Performance, Patient Outcomes. You may choose Number 1 only, Numbers 1 and 2, or Numbers 1, 2, and 3. CHPE
will assist with the appropriate evaluation as needed.
1. Learner Competence
Analyzes changes in learners. How will this be determined?
Check as applicable:
Use of UMMC’s standard evaluation form completed by the program participant immediately following the activity.
See Attached Evaluation Sample
If a UMMC standardized evaluation form will not be used, please attach a copy of the proposed evaluation
form. It must be approved by the UMMC Division of CHPE.
Use of a pre and/or post-test - attach a copy
Other process - please specify and attach a copy Label Attachment D1
2. Learner Performance (In addition to number 1)
Identifies change, plans for and/or implements desired changes needed for improving professional
practice. Impacts of program improvements are measured. How will this be determined?
Check the following as applicable:
Follow-up with learners to determine if changes or improvements were implemented or underway
Example: Three month post activity - follow-up survey to see if identified improvements on post activity
survey by email, mail or phone were implemented by the learner. Attach documentation.
Other process - please specify and attach documentation:
Label Attachment D2
3. Patient Outcomes (In addition to numbers 1 and 2)
Integrates CE into improving practice. Identifies factors that impact on patient outcomes. Addresses barriers
to change. Builds bridges. Participates for quality improvement. How will this be determined?
Follow-up via non-educational strategies. Examples: Reminders to learners, patient feedback
Other process – specify and attach documentation Label Attachment D3
Following the activity, evaluation results must be compiled, reviewed and maintained in the UMMC Division of CHPE and School of
Nursing CNE office as applicable.
1. Who will review the results of the program evaluation?
2. How will the evaluation data be used?
PART E – FINANCIAL ASSISTANCE
1. Do you anticipate financial assistance from commercial and/or nonprofit organizations?
If yes have you contacted these sources?
If yes, attach copies of correspondence or other documentation Label Attachment E
CHPE will assist with letters of invitation and/or on-line financial applications.
Terms, conditions, and purposes of commercial support must be documented in a written agreement between the commercial
entity and provider and, if applicable, the joint sponsor. UMMC LOA may be used or the commercial supporter may provide
their own. See Attached UMMC LOA
All monies should be made payable to UMMC-Continuing Health Professional Education.
PART F – DISCLOSURE RESPONSIBILITY
Disclosure of financial support or financial relationships between the author(s), speakers, planners, and others who have control over
the content for this activity and commercial entities is required. Disclosures must be made available to the participants prior to the
educational activity. Verbal disclosure should be made at the activity also. All forms to be returned with this application.
Complete Attachment F1 Disclosure Forms
Monitor Critique Forms
Documentation that verifies adequate disclosure occurred must be made via the UMMC Disclosure Monitor Critique form. These
forms must be returned immediately following the activity.
Complete Attachment F2 Disclosure Monitor Critique Forms
PART G – REPORTING SCIENTIFIC RESEARCH
A presentation reporting the results of scientific research must be accompanied by a detailed outline of the presentation which shall be
used by the UMMC faculty course director to confirm the scientific objectivity of the presentation. Such information must conform to
the generally accepted standards of experimental design, data collection and analysis. The joint sponsor should request outlines of
presentations reporting scientific research, review the outlines with the UMMC faculty course director and provide UMMC CHPE
with documentation of the process.
PART H – ACTIVITY BUDGET
All activities are cost accounted on an individual basis. Projected income and expenses are determined through discussion with the
course director/planning committee and the CHPE program administrator assigned to the activity when the activity is directly
sponsored or jointly sponsored and managed in entirety by CHPE. The program administrator will keep the course director apprised
of all income and expenses throughout the planning and implementation of the activity. Upon completion of the activity a final budget
analysis will be communicated to the course director. If the activity incurs a surplus this may be used for future activities; if the
activity incurs a deficit the sponsoring department/division, or if applicable, the joint sponsor shall be responsible for reimbursing
If the activity has a deficit, what will be the mechanism of reimbursement used (example UMMC account number):
PART I – NON-ACCREDITED JOINT SPONSORSHIP/CO-PROVIDERSHIP FOR CE ACTIVITIES
(Complete if applicable)
An entity with a commercial interest cannot take the role of a non-accredited partner.
Joint sponsors partnering with CHPE must provide projected income and expenses, submit a non-refundable $500 application fee,
reimburse CHPE for any and all expenses incurred during the planning and implementation of the activity and submit a $20 per person
fee for all participants requiring credit certificates. Following the activity, a final income and expense report must be submitted.
Name of joint sponsor person(s) providing reports and fees:
As the provider UMMC is responsible for ensuring compliance with all ACCME Essential Areas and Elements, including the
Standards of Commercial Support, for physician credit and ANCC criteria for nursing credit and retains responsibility for:
a. Needs assessment identification f. Evaluation methods
b. Determination of educational objectives g. Awarding contact hours
c. Selection and presentation of content h. Record-keeping procedures
d. Selection of all persons in a position to control content i. Budget
e. Selection of educational methods
By signature below the signee agrees to abide by all of the above.
UMMC FACULTY COURSE DIRECTOR/NURSE LEAD PLANNER:
School of Medicine (Department of Medicine Only) ____________________________________________ Date:_______________
Chair or Designee
JOINT SPONSOR COURSE DIRECTOR (if applicable):_____________________________________________ Date:_______________
For CE Office Use
____________________________ Date: ______________ ________________________________Date:______________
Sally Self, MSW P. Renee Williams PhD, RN, ICCE
Coordinated Care Department Director, Continuing Education SON
_______________________________ Date: ________________ ____________________________________Date:________________
Randy Pittman, Pharm D Shirley Schlessinger, MD, Director
Division of Pharmacy Professional Development Division of Continuing Health Professional Education
COMPLETE ONLY IF NURSING CREDIT REQUIRED
University of Mississippi Medical Center School of Nursing
500 North State Street, Jackson MS 39216
The UMMC Planning Form
NURSING CONTINUING EDUCATION DESIGN I (ED I)
The University of Mississippi School of Nursing (SON) is approved by the Mississippi Nurses Foundation as an approved provider of continuing
education for nurses. In order to receive nursing credit, read and complete this abbreviated form and submit with the UMMC application. This form may
only be used when a UMMC CHPE application is also completed in its entirety. If applying only for nursing credit, a complete SON Planning Form must
Educational Design I (ED I)/ Provider Directed: An activity involving participant attendance. It is distinguishable by the fact that the pace of the activity
is determined by the provider who plans and schedules the activity. This continuing nursing education activity is a systematic professional learning
experience designed to augment the knowledge, skills, and attitudes of nurses and therefore enrich the nurses’ contributions to quality health care and
their pursuit of professional career goals. Contact hours are awarded based on the time allocated for the activity. Examples may include but are not
limited to: conventions, courses, seminars, workshops, lecture series, and distance learning activities such as teleconferences and audio conferences.
Knowledge and use of adult learning principles should be reflected in all aspects of the educational design, e.g., objectives, content, teaching methods,
A. QUALIFIED PLANNERS AND PRESENTERS (Attachment A)
1. The planning committee is made up of at least two (2) members. One member, The Director of Continuing Education
for Nursing, Lead Nurse Planner, is administratively responsible for the educational activity, and verifying that all CHPE,
MNF, and ANCC Accreditation Program criteria in the provision of continuing nursing education have been met. The
Nurse Planner serves as the content expert and is responsible for planning and producing the educational activity while
adhering to ANCC Accreditation Program criteria in the provision of continuing nursing education. The Lead Nurse
Planner must be a registered nurse who holds a baccalaureate degree in nursing or higher.
B. EFFECTIVE ACTIVITY DESIGN (Attachment C1/B)
Time frames, topics, presenters, objectives/content, teaching strategies, evaluation tool, evaluation category,
must be in a seven-column format to provide documentation on the Attachment C1/B.
Please select any of the following as it applies to how this activity will enrich the nurse’s contribution to quality health care
and pursuit of professional career goals:
Expands the nurse’s knowledge and skills in providing quality health care
Enhances the nurse’s clinical skills in providing quality health care
Enriches the nurse’s opportunities for new career goals in the changing job market
Provides opportunities for the nurse to continue the process of life-long learning
Provides opportunities for the nurse to learn the newest techniques in providing quality health care
Purpose/goal must be included, as listed, on the evaluation form.
C. PROMOTIONAL STATEMENTS:
Submit a copy of any publication (brochure, flyer, etc.) related to this activity with the appropriate
1. After an activity is approved, the following language must appear on all CE publicity related to the activity
(brochures, flyers, etc.):
The University of Mississippi School of Nursing is an approved provider of continuing nursing education by the
Mississippi Nurses Foundation, Inc. an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
As an approved provider, the University of Mississippi School of Nursing designates this offering as meeting the
criteria for (number) contact hours.
3. Before an offering has been awarded contact hours, the following language may be used on any CE publicity related to
the activity (brochures, flyers, etc.):
The University of Mississippi School of Nursing is an approved provider of continuing nursing education by the
Mississippi Nurses Foundation Inc., an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
Contact the University of Mississippi School of Nursing Continuing Education Program for the number of contact
hours awarded for this program, 601-984-6208.
4. Accredited status refers only to continuing nursing education activities and does not imply ANCC Commission on
Accreditation approval or endorsement of any commercial products.
APPROVED PROVIDER: The University of Mississippi School of Nursing _____________________________________
TITLE OF ED I Program:
Nurse Planner completing this form (Please Print): Signature: _________________________________
Person administratively responsible: P. Renée Williams, PhD, RN, ICCE Signature: _______________________________________
Name: Lead Nurse Planner
Title of Activity: Planner (___target audience/___expert)
Date of Presentation: Administrator – Director of CNE
Degree Year Institution__________________________________________________
Present Employer Title Description____________________________________
(SEE ATTACHED DISCLOSURE FORM)
I. Have you received anything of value from a commercial supporter, which may be perceived as direct or indirect
interest in the subject(s) you are addressing in this education activity?
NO YES – List the commercial supporter:
II. If there is a commercial supporter, please describe your relationship:
speaker’s bureau major stockholder shareholder
consultant large gift(s) grant/research support
no relationship other, please describe:
III. Describe professional experience or areas of expertise (including publications) related to the
involvement in continuing nursing education.
IV. During your presentation, will you include discussion of an unlabeled or the investigational use of a product,
device or drug that has not been approved by the FDA, for the use being presented in this education activity?
NO YES - *Explain:
* If yes, you must disclose this information during your presentation. Select which method:
verbally during presentation handouts audiovisuals other
*How will conflict of interest be resolved?
V. Identify how you, as the presenter/content specialist/planner, took part in the planning and evaluation of this
planned objectives/content reviewed evaluation summary
planned time frame will utilize evaluation to revise presentation as needed
planned teaching strategies received up-to-date ANCC Accreditation standards
attended committee meetings other
Signature of Planner/Presenter/Content Specialist Date
(Vested Interest/Disclosure Form)