Mississippi Nurses Foundation, Inc. Individual Educational Activity Application (Effective )

Mississippi Nurses Foundation, Inc. Individual Educational Activity Application (Effective 01.01.13) Provider Application Organization's Name: SECTION 1 Organizations interested in submitting an application for approval of an individual educational activity must complete: Individual Activity -Organization Eligibility Verification Form 1 or if already completed a form previously sign below The applicant organization has previously completed an Eligibility Verification Form in the past six months and submitted it to the Mississippi Nurses Foundation, Inc. The information contained on the Eligibility Verification Form remains unchanged and accurate. Date Form Submitted: Individual Activity-Organization Eligibility Commercial Interest Addendum (if applicable), Is this continuing education? Does it enable the learner to acquire or improve knowledge or skills that promote professional or technical development to enhance the learner s contribution to quality health care and pursuit of professional career goals? Yes No If no, the activity is not eligible for approval. SECTION 2 Demographic Data: Title of Activity: Number of Contact Hours: Activity Type: Live Live Activity Date: Enduring Material/Web-Based Start Date for Enduring Material/Web-Based Activity: Expiration Date for Enduring Material: Other: Describe: Nurse Planner contact information for this activity: Name & Credentials: Contact Information: Page 1 of 23

Key Element 1: Assessment of Learner Needs: A. Type of needs assessment method used to plan this event? (Check all that apply) Written Needs Assessment Learners/Management Requested Event Quality Studies/Performance Improvement Activities Trends in Literature, Law & Health Care Other: Describe: B. Identify the target audience expected to attend: All RNs APNs RNs in Specialty Areas (Identify Specialty) : LPNs Multidisciplinary (Describe): Other (Describe): C. Describe the source of the supporting evidence for the needs assessment and target audience identification. (Check all that apply. You should be able to access this data upon request) Annual employee survey Literature Review Outcome Data Periodic surveys of stakeholders or learners Quality Data Requests (e.g., via phone, in person or by email) Written evaluation summary requests Other: Describe: Evidence to support findings of needs assessment data is attached and available upon request. (e.g., survey data reference in literature, QI data, etc.) D. Describe how objectives, content and teaching methods reflect the needs assessment. (Check all that apply) Nurse Planner and planning committee reviewed needs assessment data. Nurse Planner and planning committee formulated the objectives based on the data. Faculty/Presenters/Authors worked with Nurse Planner and planning committee to develop objectives, content and teaching methods. Other: Describe: Key Element 2: Qualified Planners and Faculty or Presenters: Please complete the table below for each person on the planning committee and include name, educational degree(s), credentials, and role on the planning committee. Planning committees must have a minimum of a 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. One planner needs to have appropriate subject matter expertise for the educational activity being offered. Page 2 of 23

A. Planning Committee: Committee Member Name Credentials Degrees Role on Committee Select one. Select one. Select one. Select one. The Nurse Planner holds a baccalaureate degree in nursing (BSN) and is current on CE criteria through (check all that apply): Reviewed the most current ANCC criteria as provided by the Mississippi Nurses Foundation, Inc. Other - Describe: Biographical/COI Form 2 for Planning Committee Members including conflict of interest/conflict resolution for each planning committee member is attached. Identification, evaluation and resolution of conflict of interest for planning committee members: 1. Conflict of interest evaluation for the Nurse Planner of this educational activity. a. Nurse Planner s name: b. Does the Nurse Planner have a relationship with a commercial interest organization that is relevant to the content of this educational activity: Yes* No * if yes, Nurse Planner must be recused from this educational activity c. Individual responsible for reviewing conflict of interest information for Nurse Planner (Nurse Planner may not evaluate his/her own conflict of interest information): 2. The Nurse Planner is responsible for evaluating whether any planning committee member has a relationship with a commercial interest organization. For each planning committee member, the Nurse Planner must document the following (document on each planner s conflict of interest form): No relevant relationship with a commercial interest exists. No resolution required. Relevant relationship with a commercial interest exists. The relevant relationship with the commercial interest is evaluated by the Nurse Planner and determined not to be pertinent to the content of the educational activity. No resolution required. (Documentation should reflect rationale for content not pertinent). Relevant relationship with a commercial interest exists. The relevant relationship with the commercial interest is evaluated by the Nurse Planner and determined to be pertinent to the content of the educational activity. Resolution is required. 3. In reviewing the bio forms, did the Nurse Planner and/or planning committee suspect that there might be COI and/or potential for bias for any planning committee members that was not self-reported on the form? Yes No If yes, what was the concern? What was done to resolve it? Page 3 of 23

4. Procedures used to resolve conflict of interest or potential bias, if applicable for this activity (document resolution process on each planner s conflict of interest form as applicable): Not applicable since no conflict of interest. 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. 5. Identify Content Reviewer if used as part of the resolution process on each planner s conflict of interest form. Conflict of interest must also be evaluated for the Content Reviewer. B. Presenters must have documented qualifications that demonstrate their education and/or experience in the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. The qualifications must address how the individual is knowledgeable about the topic and how expertise has been gained. Presenters do not have to be nurses, but nurses should address nursing care and nursing implications, as applicable. Be sure the Bio/COI Form contains information specific to this activity. If using the Educational Planning Table, faculty/presenters/authors should be included. Faculty/Presenter/Author Name Credentials Degrees Biographical/COI Form 2 for Faculty and Presenters with conflict of interest, conflict resolution & offlabel use declaration for each faculty/presenter/author is attached. C. Describe how the needed qualifications of faculty/presenters/authors are identified: (Check all that apply). Content expertise Demonstrated comfort with teaching methodology (e.g., web-based, etc.) Presentation skills Familiarity with target audience Other - Describe: D. Planning committee assures the qualifications of the faculty/presenters/authors are appropriate and adequate by: (Check all that apply) Review of resume/cv of faculty/presenter/author. Recommendation by colleagues. Review of literature written by faculty/presenter/author. Observation of previous presentation by faculty/presenter/author. New faculty/presenter/author being mentored by: Other - Describe Key Element 3: Effective Design Principles Page 4 of 23

A. Identified Gaps: What is missing (List any gap in knowledge, skills and/or practice based on the needs assessment) that identifies the need for this activity? Gap in Knowledge Gap in Skills Gap in Practice Other - Describe: B. Purpose/Goal (Stated in relation to the outcome desired of the learner at the conclusion of the activity) C. Educational Objectives: The objectives are derived from the overall purpose of the activity. Educational objectives are written statements that describe learner-oriented outcomes, which may be expected as a result of participation in the educational activity. These statements describe knowledge, skills and/or attitude changes that should occur upon successful completion of the activity. Determination of objectives is a collaborative activity between planners and presenters. Learner-oriented outcomes are expressed in measurable terms, identify observable actions and should specify one action or outcome per objective. (Note: Complete the applicable Educational Planning Table for live FORM 3 or enduring materials FORM 4. If the activity is more than 3 contact hours, submit the Educational Planning Table for a minimum of 3 hours of content along with the schedule and advertising for the full activity). D. Content and time frames: List the content for each objective on the Educational Planning Table. Content must be congruent with goal/purpose and objectives. Content must be more than a restatement of objectives and must flow from the objective. Numbering must be consistent with the related objective. For live presentations, list the timeframe for each objective. E. Teaching-Learning Strategies: List the methods, strategies, materials and resources to be used by faculty to cover each objective on the Educational Planning Table. Teaching learning strategies must be congruent with objectives and content. F. Learner Feedback: Check the best description or describe how learners will be provided feedback. Question and answers during activity. Return results of testing. Provide certificate. Follow-up communication. Other - Describe: G. Successful Completion: (Consistent with the goal/purpose, objectives and teaching and learning strategies) 1. Criteria for successful completion for live and enduring material/web-based activities include: (Check all that apply) ` Attendance at entire event or session Attendance for at least % of event Attendance at 1 or more sessions Completion/submission of evaluation form Achieving passing score on post-test. (Passing score is: %) Return demonstration Other - Describe: 2. Rationale for method selected above to determine successful completion: (Check all that apply) Goal or purpose of event indicated what was needed to successfully complete the activity. Category of evaluation selected Importance of content knowledge Importance of content application Required by employer or organization Other - Describe: 3. Partial Credit Awarded for Participation? No partial credit is awarded Page 5 of 23

Contact hours awarded based on # of minutes attended Contact hours awarded for 1/2 day (1/2 of total eligible contact hours) Contact hours awarded based on # of sessions attended H. Verify Participation Attendance/participation will be verified through sign in sheets/registration form. Signed attestation statement by participant verifying completion of entire activity. Collection of participation verification via computer log Other - Describe: Key Element 4: Awarding Contact Hours A contact hour is a 60 minute hour. Activities must be a minimum of 30 minutes (0.5 contact hours). The contact hour may be taken to the hundredths; but may not be rounded up. (e.g. 2.758 should be 2.75 or 2.7, not 2.8) A. Live Events: If the activity is 3 hours or less, the time frames including evaluation can be placed on Educational Planning Table. Clearly state time spent on welcome, introductions, pre/post tests, presentation, clinical experience, breaks and evaluation. If the activity is more than 3 hours, include 3 hours of content on the Educational Planning Table plus an agenda or schedule and advertising for the entire event. The time frames must match and must support the contact hour calculation. B. Enduring materials (print, CD,web-based, etc.): 1. Contact Hour Calculation: What was the method for calculating the contact hours? (Select one) Pilot Study Historical Data Complexity of content & data Other - Describe: Show evidence/(math calculation) of how contact hours were determined: Key Element 5: Evaluation FORM 5 A. Check or describe the methods of evaluation to be used: (Check all that apply) Evaluation Form (Required: Evaluates each objective and each faculty/presenter/author - Attach copy) Pre and/or Post-test (Attach a copy if testing is to be used) Return Demonstration Other - Describe: (Attach a copy) B. Categories of Evaluation 1. The category of evaluation to be used for this activity and completed by the end of the learning experience: (Check all that apply) Learner satisfaction (simplest; e.g. standard evaluation form) (Required and attach a copy) Knowledge enhancement (e.g. testing, participation, etc.) Skill and attitude change (e.g. return demonstration) Other - Describe: 2. Are advanced categories of evaluation included? Yes** No If yes, answer the following and describe how and when the data will be collected. Change in practice/performance (usually done 3 months after learning; e.g. self-report of change, observation of performance, audits, etc.) Relationship of the practice change to quality of service (most complex, usually done 6 months after event; look at final outcomes) Page 6 of 23

** Describe how and when the data will be collected for the advanced categories of evaluation listed above: Key Element 6: Approval Statement as noted on advertising All communications, marketing materials, certificates, and other documents that refer to awarding contact hours or continuing education credit for an individual education activity must include the approval statement of the accredited organization. The approval statement must be displayed clearly to the learner and must be worded correctly according to the most current criteria provided by the Mississippi Nurses Foundation, Inc. The approval statement must stand alone on its own line of text. A. Type of advertising to be used: Flyer/brochure Memo/Letter Meeting Notice E-mail Web site Social Media Other - Describe: B. Submit a copy of the advertising material including relevant pages of the web site (if applicable). The approval statement must stand alone on its own line of text and be worded as noted below. Copy of advertising materials is attached. If advertising is released prior to approval AND after an application has been submitted, the following statements may be used: This activity has been submitted to the Mississippi Nurses Foundation, Inc for approval to award contact hours. The Mississippi Nurses Foundation, Inc is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Please call (Mississippi Nurses Foundation, Inc, 601-898-0850) for more information about contact hours. If the advertising is to be released after approval is received, then use the following statement: This continuing nursing education activity was approved by the Mississippi Nurses Foundation, Inc, an Accredited Approver by the American Nurses Credentialing Center s Commission on Accreditation. Key Element 7: Documentation of Completion. Learners received documentation of success completion of the educational activities. Document/certificate must include: Name of learner (may use unique ID - do not use social security numbers) Contact information or the event provider (Name, address and phone number or email) Title and date of completion of educational activity Official approval statement Number of contact hours awarded Page 7 of 23

Copy of completed certificate to be awarded to learners is attached (sample FORM 6). Key Element 8: Commercial Support and Sponsorship A commercial interest is defined by ANCC as any entity either producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients. Exceptions are made for non-profit or government organizations and non-health care related companies. Commercial Support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. A sponsor is identified as an organization that does not meet the definition of commercial interest. Sponsorship is financial, or in-kind, contributions given by an entity that is not a commercial interest, which is used to pay all or part of the costs of a CNE activity. If no commercial support or sponsorship received, select A. If commercial support or sponsorship is received, complete items B, C, and D and attach the signed agreement(s). A. This activity has no commercial support or sponsorship. B. Commercial support/sponsorship has been provided by the following: (List name of organization(s) providing commercial support or sponsorship.) C. Content integrity has been/will be maintained by: (Check all that apply) Our commercial support/sponsorship policy/procedure has been discussed with those providing commercial support or sponsorship. Our commercial support/sponsorship policy/procedure has been shared in writing with those providing commercial support/sponsorship. Faculty/presenters/authors have been informed of our policy/procedure re: commercial support and sponsorship and agree to not promote the products or entity providing the financial or in-kind services. In conjunction with above, the session will be monitored and violators of policy will not be asked to present again. Other - Describe: D. The following precautions have been taken to prevent bias in the educational content: (Check all that apply). Our position on commercial support/sponsorship and bias has been discussed with each presenter. Each faculty/presenter/author has signed a statement that says s/he will present information fairly and without bias. In conjunction with the above, the session will be monitored and violators of policy will not be asked to present again. Other - Describe: E. Signed commercial support or sponsor agreement attached (FORM 7). Key Element 9: Conflict of Interest A. Documentation of conflict of interest or disclosure of absence of conflict of interest for planners and faculty/presenters/authors is included on the attached Biographical/COI Forms. Biographical/COI Forms for all planners and faculty/presenters/authors are attached. B. In reviewing the bio forms, did the Nurse Planner and/or planning committee suspect that there might be COI and/or bias for any planning committee members and/or faculty/presenters/authors not self-reported on the form? Yes No Page 8 of 23

If yes, what was the concern? What was done to resolve it? C. 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. Have discussed this conflict with individual (planner, presenter, or author) who is now aware of and agrees to our policy. Presenter has signed a statement that says s/he will present information fairly and without bias. In conjunction with the presenter agreeing with our policy and signing a statement, the nurse planner or designee will monitor session to ensure conflict does not arise. Other - Describe: Key Element 10: Written Disclosures Provided to Participants Learners must receive written or verbal disclosure of required items prior to beginning the learning activity. Disclosures are required to be provided for items A through D for each learning activity. Disclosures for items E and F apply only in relevant situations. Attach copies of documents or describe methods used to inform activity participants of: A. Goal/Purpose, objectives and criteria for successful completion (Note: Not applicable or n/a is not an acceptable response) Information on advertising material. Written information on handouts for activities/directions (Attach copy). Verbal statement and someone in the audience will witness and document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) Other - Describe: (Attach copy) B. Lack of Conflict of Interest for planners and presenters, including financial relationships: (Check all that apply) Planners disclose no conflict of interest relative to this educational activity Faculty/presenters/authors disclose no conflict of interest relative to this educational activity ** Lack of conflict of interest disclosed to learners by: Information provided in advertising. Information provided on handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) Other - Describe: (Attach copy) If there is no disclosed conflict of interest by planners and faculty/presenter/author, skip C. C. Conflicts of interest for planners and presenters, including financial relationships, and resolution of such: (Check all that apply) Planners disclose a conflict of interest relative to this educational activity Faculty/presenters/authors disclose a conflict of interest relative to this educational activity ** Conflict of Interest disclosed to learners by: Information provided in advertising. Information provided on handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Page 9 of 23

Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) Other - Describe: (Attach copy) D. Commercial support/sponsorship or lack thereof Not applicable Information provided in advertising. Information provided in handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Verbal statement and someone in the audience will document the verbal disclosure (Reminder: place a signed notation in the file to describe the verbal disclosure) Other - Describe: (Attach copy) E. Non-endorsement of products displayed in conjunction with this activity. Not applicable No products are being displayed. (No statement needed.) Information provided in advertising. Information provided in handouts. (Attach copy) Information provided in print at the start of the non-live activity (Attach copy) Other - Describe: (Attach copy) F. Discussion of off-label use: Not applicable Faculty/Presenters/Authors have attested that they will not discuss off-label usage of products. (No statement needs to be made.) Information will be provided in hardcopy or via electronic media. (Attach copy) Other: Describe: (Attach copy) G. Expiration date for awarding enduring materials contact hours: Not applicable - not enduring material Learners notified how long contact hours will be awarded for the activity on advertising. Learners notified how long contact hours will be awarded for the activity on directions page. Key Element 11: Recordkeeping A. Planning: All correspondence including a copy of this application Planning documentation should include: Target audience description Methods and findings of the needs assessment Names, titles and expertise of the planners and faculty/presenters Bio/COI statements from planners and faculty/presenters Learning goals, objectives and content Instructional strategies, delivery methods, learner feedback and resources to be used Methods or processes used to verify participation Notice to learners identifying how successful completion will be measured Marketing and promotional materials Division of responsibilities among co-providers (if applicable) Signed Co-provider Agreement Means of ensuring content integrity for educational activity with commercial support (if applicable) Signed Commercial Support Agreement B. Implementation: Implementation documentation should include: Title, location and date of educational activity All evaluation tools used, including a summative evaluation upon completion of the activity Page 10 of 23

Participants name and unique identifier information Sample certificate of completion Number of contact hours associated with approval statement awarded to individual participants Documentation of any verbal or written disclosures C. Activity File to be stored at (list location): Key Element 12: Co-Providership Form 8 If activity will not be co-provided, select A; If activity will be co-provided, select B and attach signed co-provider agreement. A. This activity will not be co-provided. B. Co-providership of this activity has been arranged with: List organization(s) name(s): As the event provider, we maintain responsibility for determination of educational objectives and content, selection of content specialists and activity presenters, awarding of contact hours, record keeping procedures, evaluation methods and categories, and management of any commercial support or sponsorship. C. The signed, written co-provider agreement is attached (FORM 8). D. Event provider must be prominently displayed in marketing material. Statement of Understanding An X in the box below serves as the electronic signature of the individual completing this Individual Education Activity Application and attests to the accuracy of the information given above. Electronic Signature (Required for electronic submissions) Completed By: (Name and Credentials) Date Page 11 of 23

Section 1: Eligibility MISSISSIPPI NURSES FOUNDATION, INC. Individual Educational Activity Applicant Eligibility Verification Applicants interested in submitting an individual educational activity for approval must complete the Eligibility Verification and meet all Eligibility Requirements. Verification forms received from applicants that do not meet Eligibility Requirements will be rejected without substantive review. Name of Applicant Street Address City State Zip/Postal Country Identify Organization Type: Constituent Member Associations of ANA College or University Healthcare Facility Health - Related Organization Multidisciplinary Educational Group Professional Nursing Education Group Specialty Nursing Organization Other: Describe - FORM 1 Primary Point of Contact: Name and Credentials Title/Position Telephone Number E-mail Address 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: Date: Action: Denial Suspension Revocation Brief description: Has the applicant ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by the Mississippi Nurses Foundation, Inc? No Yes Page 12 of 23

If yes, please provide the following information: Date: Action: Denial Suspension Revocation Brief description: Has the applicant ever been denied approval by or had approval suspended or revoked for an individual activity or a provider application by another ANCC Accredited Approver? Yes No If yes, please provide the following information: Date: Action: Denial Suspension Revocation Brief description: A currently licensed registered nurse with 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 Please list the name and credentials of the nurse involved/responsible for this educational activity: Nurse Planner's Name Credentials Section 2: Commercial Interest The following section is intended to collect information about the applicant's corporate structure. Some applicant types are automatically exempt from ANCC s definition of a commercial interest, including: Blood banks, Constituent Member Associations, Diagnostic laboratories, Federal Nursing Services, For-profit and not for profit hospitals, For-profit and not for profit nursing homes, For profit and 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, and Specialty Nursing Organizations A single-focused organization* devoted to offering continuing nursing education (* The single-focused organization exists for the single purpose of providing CNE) NOTE: 501c applicants are not automatically exempt. The ANCC Accreditation Program requires 501c applicants to be screened for eligibility. An "X" on this line identifies the applicant as exempt from ANCC s definition of a commercial interest. Identify the applicant's exemption type from section 2 above and enter it here: Page 13 of 23

If you checked the box above, then you have completed this questionnaire, proceed to Section 5. Section 3 - Only complete this section if applicant organization is not exempt 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, so the Mississippi Nurses Foundation, Inc. can assess the applicant's eligibility. Does the applicant produce, market, re-sell, or distribute health care goods or 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 Is the applicant owned or controlled by a multi-focused organization (MFO*) that produces, markets, re-sells, or distributes health care goods or 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 5. Is the applicant a separate and distinct entity from the MFO*? Yes - If yes, continue to section 4 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 4: Commercial Interest Evaluation - Continued Does the multi-focused organization that owns the applicant have a 501-C Non-profit Status? Yes No If no, complete the next bulleted question 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. No I s any component of the multi-focused organization an entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients? Yes If yes, please describe the health care good or service consumed by or used on patients and the role of the entity in producing, marketing, re-selling or distributing those healthcare goods or services. No If no, this section of the questionnaire is complete, proceed to Section 5. Page 14 of 23

If yes, please complete and submit the Individual Activity Eligibility Commercial Interest Addendum with this Form. Section 5: Statement of Understanding On behalf of (insert name of applicant), I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of (insert name of applicant), that (insert name of applicant) will comply with all eligibility requirements and approval criteria throughout the entire approval period, and that (insert name of applicant) will notify Mississippi Nurses Foundation, Inc. promptly if, for any reason while this application is pending or during any approval period, (insert name of applicant) 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 Mississippi Nurses Foundation, Inc. to deny, suspend or terminate (insert name of applicant) s approval of this individual activity and to take other appropriate action against (insert name of applicant). (Eligibility Verification forms received without a signature incur a delay in processing which will cause a delay in the review of the individual education activity application.) An X in the box below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information contained. Electronic Signature (Required) Date Completed By: Name and Title Please return the completed Eligibility Verification Form and, if necessary, the Individual Activity Eligibility Commercial Interest Addendum with this Form to Mississippi Nurses Foundation at: foundation@msnurses.org. Page 15 of 23

FORM 2 ATTACHMENT A - Biographical/Vested Interest Check all that apply. Name: Lead Nurse Planner (Administrator) Title of Activity: Planner (target audience expert ) Date of Presentation: Presenter 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 OR YES (IF yes, list the commercial supporter: ) Describe your relationship: speaker s bureau major stockholder shareholder consultant large gift(s) grant/research support no relationship other (describe ) III. How will conflict of interest be resolved? Describe professional experience or areas of expertise (including publications) related to the involvement in continuing nursing education. IV. Identify how you took part in the planning and evaluation of this activity: 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 V. Presenter: 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 OR YES (IF 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? Signature of Planner/Presenter Date Page 16 of 23

SAMPLE (OPTIONAL) CE Attestations for Presenters/Planners with Vested Interests Please indicate your understanding of and willingness to comply with each statement below. If you have any questions regarding your ability to comply, please contact the office at 601-898-0850 as soon as possible. 1. I have disclosed to the MNF all relevant financial relationships, and I will disclose this information to learners verbally and in print. Agree Disagree 2. The content and/or presentation of the information with which I am involved will promote quality or improvements in healthcare and will not promote a specific proprietary business interest of a commercial interest. Content for this activity, including any presentation of therapeutic options, will be well-balanced, evidence based and unbiased. Agree Disagree 3. If I am presenting at a live event, I understand that a MNF monitor will be attending the event to ensure that my presentation is educational, and not promotional, in nature. Agree Disagree 4. I will use generic names to the extent possible when discussing specific health care products or services. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company. Agree Disagree 5. If I am discussing any product use that is off label, I will disclose that the use or indication in question is not currently approved by the FDA for labeling or advertising. Agree Disagree 6. If I have been trained or utilized by a commercial entity or its agent as a speaker for any commercial interest, the promotional aspects of that presentation will not be included in any way with this activity. Agree Disagree 7. If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principles and methods, and will not promote the commercial interest of the funding company. All scientific research referred to, reported or used in the activity in support of justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection, and analysis. Agree Disagree 8. I understand that MNF may need to review my presentation and/or content prior to the activity, and I will provide educational content and resources in advance as requested. Agree Disagree I have carefully read and considered each item in this attestation form, and have completed it to the best of my ability. Signature Date Page 17 of 23

I N D I V I D U A L A C T I V I T Y P R O V I D E R ' S N A M E E D U C A T I O N A L P L A N N I N G T A B L E - L I V E FORM 3-EDI-ATTACH B Title of Activity: Identified Gaps: Purpose: (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to.. OBJECTIVES List learner s objectives in behavioral terms CONTENT (Topics) Provide an outline of the content for each objective. It must be more than a restatement of the objective. TIME FRAME State the time frame for each objective PRESENTER List the Faculty for each objective. TEACHING METHODS Describe the teaching methods, strategies, materials & resources for each objective 1. 2. 3. E V A L U A T I O N T I M E ( 1 0-1 5 M I N U T E S ) Total Minutes divided by 60 = contact hour(s) Completed By: Name and Credentials Date Nurse Planner Signature: Page 18 of 23

P R O V I D E R ' S N A M E FORM 4 - EDII-ATTACH B E D U C A T I O N A L P L A N N I N G T A B L E - E N D U R I N G M A T E R I A L ( 2 0 1 3 C R I T E R I A ) Title of Activity: Identified Gap(s): Description of current state: Description of desired/achievable state: Gap to be addressed by this activity: Knowledge Skills Practice Other: Describe Purpose: (write as an outcome statement, e.g. "The purpose of this activity is to enable the learner to.. ) OBJECTIVES List learner s objectives in behavioral terms 1. CONTENT (Topics) Provide an outline of the content for each objective. It must be more than a restatement of the objective. AUTHOR List the author for each for each objective. 2. 3. List the evidence-based references used for developing this educational activity: EVALUATION TIME (10-15 MINUTES) Method of calculating contact hours: Pilot Study Historical Data Complexity of Content Other: Describe Estimated Number of Contact Hours to be awarded: Completed By: Name and Credentials Date Page 19 of 23

FORM 5 - SAMPLE EVALUATION - Provider Overall purpose(s)/goal(s): TITLE: DATE: LOCATION: PROVIDER: OBJECTIVES At the end of this activity, the participant should be able to: 1. 2. 3. 4. 5. Etc. Please fill in one response per line. 1. To what extent was the overall purpose(s)/goal(s) of this activity related to the objectives? Low/Poor High/Excellent Non-Applicable 1 2 3 4 5 N/A 2. To what extent did the presenter address each objective? Objective 1: Objective 2: Objective 3: Objective 4: Objective 5: Etc: 3. To what extent did each presenter demonstrate expertise in the content area: Presenter (Name) Presenter (Name) Presenter (Name) 4. To what extent were the teaching/learning strategies appropriate? 5. Did you detect any commercial bias? YES NO If so, by whom? What made you feel there was bias? PLEASE MAKE WRITTEN COMMENTS ON REVERSE SIDE. Page 20 of 23

FORM 6 - SAMPLE Attendance Verification OR Certificate PROVIDER S NAME This participant has successfully completed this educational activity: Educational Design # Name of Participant: Contact Hours: (60 minutes = 1 contact hour) Provider of Educational Activity: Title: Address of Provider: Date: This continuing nursing education activity was approved by the Mississippi Nurses Foundation, Inc., an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. MISSISSIPPI NURSES FOUNDATION 31 Woodgreen Place, Madison, MS 39110 601-898-0850 foundation@msnurses.org Page 21 of 23

FORM 7-SAMPLE COMMERCIAL SUPPORT OR SPONSORSHIP AGREEMENT *(ORGANIZATIONS PROVIDING COMMERCIAL SUPPORT OR SPONSORSHIP MAY NOT PROVIDE OR CO- PROVIDE AN EDUCATIONAL ACTIVITY) Date: This educational activity Title of activity is being supported by: Name of Commercial Supporter or Sponsor The Commercial Supporter or Sponsor agrees to provide the following services: Unrestricted educational grant for support of the CE activity in the amount $ Restricted educational grant to reimburse expenses for: 1. Speaker(s) to include: all expenses travel only consulting fee only Other 2. Support for catering functions (specify) in the amount of $ 3. Other (e.g. equipment loan, brochure distribution, etc.) in the amount of $ Written policies and procedures and documentation governing honoraria and reimbursement of out-of-pocket expenses for planners, presenters, and authors are on file with the continuing education provider. The Continuing Education Provider will ensure that the following decisions are made free from control of a commercial interest or bias. The commercial supporter or sponsor will not assess, plan, implement, or evaluate this educational activity: Identification of educational activity needs; Determination of educational objectives; Selection of presentation of content; Selection of presenters or faculty; Selection of educational methods; Evaluation of the educational activity. It is understood that the commercial supporter or sponsor will adhere to the provider s policies/procedures: 1. Learners will be made aware of the nature of all commercial support or sponsorship of all education activities on all promotional materials. Attach a copy. 2. Funds should be in the form an educational grant and must be acknowledged in printed material and/or brochures. 3. Arrangements for commercial exhibits will not influence the planning of or interfere with the presentation of education activities. 4. Education activities are distinguished as separate from endorsement of commercial products. When commercial products are displayed, participants will be advised that accredited status as a provider refers only to its continuing education activities and does not imply ANCC Commission on Accreditation endorsement of any commercial products. 5. Education activities that present research conducted by commercial companies will be designed and presented with scientific objectivity. 6. Learners will be informed in the presentation is about the off-label use of a product (using products other than that for which it was approved by the Food and Drug Administration.) Commercial Supporter or Sponsor Signature Date Educational Provider Signature Date Page 22 of 23

FORM 8-SAMPLE CO-PROVIDERSHIP AGREEMENT (An entity with a commercial interest cannot take the role of a partner in a co-provider relationship.) Title of Educational Activity: Date: Location: Name of Provider Agency: Name of Contact Person: Address: Phone: Email: (Lead-Approved Provider Unit) is responsible for ensuring adherence to all ANCC criteria and retains responsibility for ANCC accredited provider unit: 1. Determination of the educational objectives and content 2. Selection of the content specialist planners and activity presenters 3. The awarding of contact hours 4. Record-keeping procedures 5. Evaluation methods Name of Co-Provider Agency Name of Contact Person Address: Phone: Email: Signature of Provider Representative: Date: Signature of Co-Provider Representative Date Page 23 of 23