Please complete the following information when preparing to offer a previously awarded continuing education course. Classes may be offered numerous times within the three-year period of the course.

Course content and objectives must be the same. Once the course has expired or if content and/or objectives change, a new Continuing Education Planning Form is required.

Return form electronically to: cppn@health.ucdavis.edu at least 30 days prior to date of course.

Requested by: Click here to enter text.
Date: Click here to enter a date.
Unit: Click here to enter text.
Phone: Click here to enter text.
Course Title: (Must be same as on CE Planning Form) Click here to enter text.
Course Code: Click here to enter text.
Original Date of Course Offering: Click here to enter a date.
Choose from the following as applies to the course: ☐ CPPN-based class (advertised on CPPN website) - CPPN Coordinator: Click here to enter text. ☐ Unit-Based class ☐ ANCC – CPPN Nurse Planner: Click here to enter text. ☐ ACE class (for LCSWs) ☐ eLearning
New Date(s) for Course: Click here to enter a date. Click here to enter a date. Click here to enter a date. Click here to enter a date. Click here to enter a date. Click here to enter a date. Click here to enter a date.
Number of expected attendees: (if different than original planning form) Click here to enter text.
Important Notes: All presenters, individuals involved, etc. as outlined below, are required to complete a new Conflict of Interest form every 12 months to participate in a CPPN continuing education activity. List any additional or change in presenters and attach COI form(s) Submit an agenda with presenter names with form For ACE courses, additionally provide a resume, proof of licensure, and brief bio for each presenter

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List of Individuals in a Position to Control Content
Complete the table below for each person in a position to control content of the educational activity (e.g., nurse planners, planning committee members, speakers/presenters, and content reviewers). For each individual, include name, credentials, educational degree(s), and role in the activity. Each person must submit a complete Biographical and Conflict of Interest form that validates their expertise to fulfill their respective role (annually for ongoing courses). Every person on list must complete a Biographical and Conflict of Interest (COI) form.

Name of individual and credentials (i.e., John Smith, MSN, RN, CCRN)	Individual’s role in activity Nurse Planner, Planning Committee, Content Reviewer, Presenter	Planning committee member? (Yes/No)	Name of commercial interest	Nature of relationship to the commercial interest (i.e., speaker bureau, stockholder, CEO, etc.)	COI form completed
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All the following should be sent to CPPN for attachment to final course document.
Attachment 1	Agenda with Date/Times and Presenter Name(s)
Attachment 2	Conflict of Interest forms (for ACE courses, also resumes, proof of licensures, bio statements)
Attachment 3	Commercial Support Agreement with signatures and date, if applicable
Attachment 4	Updated Course Materials (presentations, advertisements, handouts)
Attachment 5	Course Advertisements (Save the dates/Course flyers/PDF of web page)
Attachment 6	Course Evaluation forms

Requirements for completion of this program

Participant must sign in on official roster and be present for content presentation.

C.E. credit will not be awarded for this program session if the participant is more than:

5 minutes late for a course of 4 hours or less in duration or

20 minutes late for a course of more than 4 hours in duration

Specific requirements for individual course:

Conflict of interest

Conflict of interest can exist when an individual has an opportunity to affect nursing continuing professional development content in relation to an ineligible company (previously termed commercial interest) in which they have a relevant financial relationship.

Unless indicated below, all planners and presenters associated with this program no relevant financial relationships with ineligible companies with relation to the content of this program.

Off label use

This educational activity does not include any unannounced information about off label use of a product for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Potential Conflict of Interest Notification to Course Attendees (select one and describe as needed)

☐	There are no relevant financial relationships with ineligible companies (previously termed commercial interests) to disclose among planners, faculty, and everyone in control of content.

☐ Relevant financial relationships exist and are disclosed to learners below, including the names of individuals with relevant relationships, names of ineligible companies (previously termed commercial interests), the nature of relationships, and a statement that all relationships have been mitigated.

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