NCPD Request Form

We are pleased to help you plan your nursing continuing professional development activity. The process of planning begins with identifying when continuing professional development might be a desired intervention to address a change that has been made to a standard of care, a problem that exists in practice, or an opportunity for improvement. Please complete the form below to help us better understand your needs. A nurse planner will contact you within 7-10 business days.

Does this event occur in less than 45 days? *

Yes

No

Clinical Education & Professional Practice accepts NCPD requests less than 45 days prior to the event under special circumstances.

If you selected yes, please provide an explanation and we will evaluate your request in further details.

Requestor's name, credentials, contact number and email address. *

Alternate contact name, credentials, contact number and email address. *

Activity/event title: *

Will this activity have Enduring Material? *

Printed, recorded, or computer-presented CNE activity that may be used over time at various locations.

Yes

No

Will this activity be a Regular Scheduled Series (RSS)? *

A series with multiple sessions that occur on an ongoing basis (offered weekly, monthly, or quarterly).

Yes

No

Date of first presentation: *

Month

Day

Year

Please list additional dates (if applicable):

If this is an RSS series you may enter weekly, monthly, quarterly etc...

Will you have vendors? *

Yes

No

Will you charge any fees for this event? *

Yes

No

Will you be seeking/receiving Commercial Support for this continuing nursing activity? *

Commercial Interest Organization (CIO) is: any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, 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. *Nonprofit or government organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests. Commercial support is financial (monitory) or in-kind (non-monitory) contributions given by a commercial interest that are used to pay for all or part of the costs of a CNE activity. (American Nurse's Credentialing Center (ANCC) (Note: Organizations providing commercial support may not provide or joint provide an educational activity.)

Yes

No

Are you currently working with the Continuing Medical Education (CME) office? *

Yes

No

If yes, who are you currently working with in the Continuing Medical Education (CME) office?

Gap Analysis:

Please be advised in the next section, you will be asked to provide evidence that validates the purpose of this activity.

Difference between what is currently happening in practice and what should be happening in practice. *

Evidence to support the problem in practice, change in practice, or opportunity for improvement. Example: Gap in Knowledge (does not know), Gap in Skill (does not know how) and/or a Gap in Practice (Unable to show/do)

Desired outcome for this activity? How will you measure whether learners have achieved this outcome? *

How will you design the activity to increase the likelihood of learners achieving the desired outcome? *

Questions or Comments:

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Clinical Education & Professional Practice accepts NCPD requests less than 45 days prior to the event under special circumstances.