Request for Non-C.E. Activity

Information/Instructions: Please Read Carefully

Applications:

This application is for activities that will not receive continuing education contact hour credit, but will be entered into attendees UC Learning transcript.

For assistance/questions call or visit the Center for Professional Practice of Nursing office, 4900 Broadway, Suite #1630, (916) 734-9790.

Required Form Information:

Submitter Information: Coordinator of the activity

Activity Information:

Title of Educational Activity: Should be specific to content. If Activity is part of a series of an ongoing program, precede specific class title by series name.

Date(s) and Time of Activity: Planned date(s) and length of time

Target Audience: Who is the activity directed to (All inpatient RNs, PT and OT providers)

Goal for overall Activity: Stated purpose or Activity description and expectation (i.e., to in-service staff on new product name for timely and safe use.)

Activity Planning Table:

Topics and learning objectives with designated time frame,

Individuals providing the education: Names, degrees, certifications, titles of person(s) providing education.

Learning strategies: How education will be provided i.e., demonstration with return demo, educational flyers, product handout. (All printed materials need to be submitted with application)

Activities are approved for three years and may be re-offered at any time during that period.

CPPN will provide in-service rosters

Upon return of rosters data will be entered into UC Learning, and educational materials will be maintained electronically for three years after the date of the last offering.

Title of Activity: Click or tap here to enter text.
TO BE COMPLETED BY CPPN
Date received: Consent to provide course date: Renewal date: (3 years from consent to provide course) Click here to enter a date. Click here to enter a date. Click here to enter a date.
Course Code: Click here to enter text.
Application reviewed and meets criteria. CPPN Consent to provide course: Click here to enter text.

Non-C.E. Activity Planning Form

Submitter’s Contact Information
Submitted By (Name, Degree, Credentials, Title): Click here to enter text.
Department: Click here to enter text.
Telephone: Click here to enter text.
UCDH email address: Click here to enter text.
Activity Information
Title of Activity: Click or tap here to enter text.
Type of Activity: Click or tap here to enter text. ☐ Staff Inservice ☐ Skills Day/Inservice ☐ Other: (Describe
Location: Click here to enter text.
Maximum # participants for Activity: Click here to enter number.
Target Audience include Unit/Job Title: Click here to enter text.
Course Start Date: Click here to enter text. Course End Date: Click here to enter text.
Expected Time Length: Click here to enter text.
Goal/Purpose of Activity (Stated purpose or Activity description and expectation. Example: To in-service staff on new product name for timely and safe use.): Click here to enter text.
☐ Check if requesting Rosters for specific Unit(s) List Unit(s): Click here to enter text.

Activity Planning Table

Title of Activity: Click or tap here to enter text.

Content (Topics)	Learning Objectives	Time Frame	Presenter	Learning Strategies
Provide a short outline of the content/skill/topic presented and/or National Safety Goal or Nursing Quality Indicator Addressing (See attached List) List any Handouts that will be provided Insert additional row for each topic/session.	List the educational objectives Behavior/performance objectives are stated in terms of what the student or learner will do, rather than what the instructor will do. Use terminology such as Describe, Discuss, Explain, Identify, Interpret, Apply, Demonstrate, Develop, Examine, Implement, Practice, Analyze, Compare, Detect, Examine, Assess, Integrate, Manage, Prioritize, Collaborate, Communicate, Create, Facilitate, Model, Perform	in minutes	Include name and credentials (degrees, certifications, titles) of person responsible for information related to specific content/skill/topic	List the teaching strategies for each skill, topic or content area. Examples: Lecture, Video, Questions, Discussion, Review, Test, Exercises, Practice, Skill Station, Demonstrations, Role Play, Case Studies, Simulation
EXAMPLE: EVD lumbar drainage system review	EXAMPLE: Demonstrate how to prime an EVD system.	15	Tish Campbell, RN-BC	Skill review with return demonstration of skill.

Title of Activity: Click here to enter text.
Completed by CPPN	Explanation of Non-C.E. Activity form requirements – please direct any questions to cppn@health.ucdavis.edu
Title of Educational Activity: Should be specific to content. If Activity is part of a series of an ongoing program, precede specific class title by series name; i.e., IV Catheter Placement Inservice.
Date(s) and Time of Activity: Planned date(s) and time(s)
Target audience: Who is the activity directed to (All inpatient RNs, PT and OT providers)
Application submitted by: Completed by the coordinator of the class
Goal for overall Activity: Stated purpose or Activity description and expectation (i.e., to in-service staff on new product name for timely and safe use.)
Education Provided by: Names, degrees, certifications, titles, of person(s) providing education
Education Provided through: How education will be provided i.e., demonstration with return demo, educational flyers, product handout. (All printed materials need to be submitted with application)