Clinical Education Request for Course Builds
Requestor Name
First Name
Last Name
Requestor Email
*
example@example.com
Date of Request Submission
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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 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.
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**Click the submit button and a member from clinical education will be assigned this request.
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For Office Use Only
This section of the form is to be filled out by a representative of the clinical education team.
Team Lead
Additional Team Members/Instructors
What type of request is this?
Educational
Evidence Based Practice
Survey Build (Survey Monkey)
Competency Level Goals: What level of competency are you trying to achieve with this event? Select one, the highest level you wish to obtain.
Increase Knowledge (This session primarily information only and is used to increase the knowledge of the participant. Best if this is given as a huddle event, staff meeting, tip sheets, or HealthStream event and occasionally a live event)
Increase Skill/ Competence at a task (This session is designed to validate participants ability to do or perform a skill. This requires visual validation and participation in an activity. This type of event usually requires a live event.)
Change in Practice/Behavior/Attitude (This session is designed to impact overall practice by the group at large. This requires staff to have also have the knowledge, and ability to do what is asked of them. It is one step more in how they apply what they learned into the practice setting. A change in practice can only be measured by what is happening on the unit and not in the classroom. Things such as audits, surveys, or unit observations are examples of ways to validate the practice has changes. )
How do you plan to validate that a change in practice has occurred after education has been provided?
What will impact patient care, staff, cost be to Cheyenne Regional if we do not complete this education?
Type of learning event (this should be driven by competency level goals).
Tip Sheet/ Handout Development
Unit Huddles or LDM Education
Staff Meeting Education
Building Assessments and competency statements (including checklists)
On the unit just in time training
Booth or Equipment Rodeo
E-Learning Event (HealthStream Module)
Live Class Room/ webex Event
Both an E-Learning event and a live event
Large conference Symposium or all day event
Title:
Give a general overview of this project with identified course objectives. The course description here will be added to the expo brochure when necessary.
Please describe the target audience in full detail. (Be as specific as possible including Job Description # and department #, are agency included)
What teaching strategies will be used during this event to actively engage the learner, or validate acquisition of the knowledge?
Lecture and or PowerPoint (knowledge)
Pre-Test (knowledge)
Post-Test (knowledge)
Questions and Discussion time (knowledge)
Checklists (skills)
Case Study/ Problem based analysis (skills)
Simulation (skills)
Games/ Gaming Systems (knowledge or skills)
Interactive web based tools (knowledge or skills)
Shared experiences or reporting out to the group (knowledge or skills)
Other
Is eLearning work required prior to registration or attendance at class?
Yes
No
Must the participant preregister in HealthStream for this class or is it a drop in session?
Must register in HealthStream for a specific course time.
Drop in with no set registration time.
Course Length (This should be based on the number of objectives to achieve. Standard is 2 objectives per 1/2 hour.) (Listed as hours. 1/2 event list as 0.5)
Please indicate all the dates and times of the training
Date
Start Time
End Time
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
Session 10
Session 11
Session 12
Session 13
Session 14
Session 15
Session 16
Session 17
Session 18
Session 19
Session 20
Max number of participants for each class if limited.
Are there special class room or set up needs? Please list what they are.
Locations of trainings if offered out side of expo.
Is this course Mandatory, Essential, or Optional
Please Select
Mandatory- Training provided required per job description or to maintain compliance with regulatory agency such as CMS, Joint Commission, OSHA.
Essential- This type of training is essential for ensuring safe patient care and therefore, staff are required to attend. This type of training is generally new policies, new procedures, or new equipment.
Optional- This type of training is nice to have and would enhance practice. it is not required to maintain safety or regulatory compliance.
None of the Above- Information just provided to staff.
Have you met with the unit leaders that this training impacts to determine expectations regarding training needs?
Yes
No
Due date for Education.
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Month
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Date
What is the make-up plan for this event?
Is this session offering a WebEx Option?
Yes
No
Does this session need recording for enduring materials or Make-up?
Yes
No
Would you like Nursing continuing education or CME hours for this event?
Yes
No
Will this course require an Articulate or Rise 360 build? (Please allow 3 months to build a full interactive eLearning event).
Yes
No
Will Vendors or an outside agency participate or issue the training for this event?
Yes
No
Please indicate the company, name and contact information for the vendor representative.
Who will be responsible for preparing course content and providing it to clinical education/ LMS coordinator.
Will quizzes be required in the course?
No Quiz will be included in this event
A precourse quiz will be included
A post course quiz will be included
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Post Course Information
Has the event been hosted and completed?
Yes
No
Date information sent out.
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Please provide dates training was completed or information was shared.
Date
Location/ Unit
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
Session 10
Have post training rosters been obtained and recorded in HealthStream?
Yes
No
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.
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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.)
Yes
No
Will Additional Education be required as a result of this practice change? (If yes, please fill out a new request form for education. )
Yes
No
Survey Monkey Request
Title of Survey
Enter Web URL for Survey
When would you like to close the survey?
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Month
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Year
Date
Additional Notes:
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Should be Empty: