Clinical Education Request for Course Builds

Clinical Education Request for Course Builds
Requestor Name*

First NameLast Name
Requestor Email*
example@example.com
Date of Request Submission*

MonthDayYear
Date
Department Requesting this education*
Title of Training Event:*
Please describe what your project about, what is your identified educational gap, or what are you hoping to achieve by providing this education? *
Who is your target audience?*
What type of request is this?*

EducationalEvidence Based Practice Review and/or Policy ChangeSurvey Build (survey Monkey)Other
What is your time line for presenting this information or project roll out? *Please note the following time lines may impact your training request: Full Education Builds for live/ HealthStream courses may take three months or more to produce depending on the learning objectives. Huddles, tip sheets or micro learnings take less time to produce. *

MonthDayYear
Date
**Click the submit button and a member from clinical education will be assigned this request. If you are an educator filling this form out, please proceed to the next pages.

Have post training rosters been obtained and recorded in HealthStream?

YesNo
Total Number of RN's Trained.
Total Number of CNA's Trained.
Total Number of others trained.
Total number of hours Educators spent building and training course.
Number of hours spent building HealthStream curriculum.
Cost of additional educational supplies/speaker fees/ location fee/ food
Total spent on RN participation in training
Total spent on CNA participation in training
Total spent on Other roles participation in training
Total spent on Nursing Educator/ Trainer time to build and issue training materials
Total spent for LMS designer to build and issue training materials
Estimated cost of this training event.

Evidence Based Practice Review
What is the practice concern or question?
What evidence was found to support or not support the question?
Will this EBP concern or question create a practice change or project management request? (If yes, please proceed to present this information to applicable change committees for review.)

YesNo
Will Additional Education be required as a result of this practice change? (If yes, please fill out a new request form for education. )

YesNo
Survey Monkey Request
Title of Survey
Enter Web URL for Survey
When would you like to close the survey?

MonthDayYear
Date
Additional Notes:
Should be Empty:

**Click the submit button and a member from clinical education will be assigned this request. If you are an educator filling this form out, please proceed to the next pages.