Document Sample

              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
Medical Center.
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
     Professional Education.
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 Title:
Activity Date(s):
Activity Location (City, State, Facility):
Sponsoring School/Department/Division:
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
commercial entities.)

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
    Pharmacists: ACPE
    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:

  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

   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

   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

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?

   1. Do you anticipate financial assistance from commercial and/or nonprofit organizations?
             YES                NO
         If yes have you contacted these sources?
             YES                NO
                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.

Disclosure Forms
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

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.

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):

(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.

____________________________________________________________________________________________ Date:_______________

School of Medicine (Department of Medicine Only)      ____________________________________________ Date:_______________
                                                              Chair or Designee

JOINT SPONSOR COURSE DIRECTOR (if applicable):_____________________________________________ Date:_______________

For CE Office Use
Approved by:
____________________________ 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

Rev 3/09

                             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
be used.

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,
          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.

                 Submit a copy of any publication (brochure, flyer, etc.) related to this activity with the appropriate
                 ANCC language:
                   EDUCATION DESIGN
          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: _________________________________

Department:        Phone:

Person administratively responsible: P. Renée Williams, PhD, RN, ICCE Signature: _______________________________________

                                                      ATTACHMENT A
Name:                                                                       Lead Nurse Planner
Title of Activity:                                                          Planner (___target audience/___expert)
Date of Presentation:                                                       Administrator – Director of CNE

Biographical Data
Degree                   Year             Institution__________________________________________________

Present Employer                          Title              Description____________________________________


Vested Interest
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)


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