CE Offerings Application 2.27.2017

Continuing Education Offerings Application Process

Use this form for the following types of continuing education:

Emergency Medical Services Agency (EMT/EMT-P)
Physical Therapy Board of California
Speech-Language Pathology, Audiology and Hearing Aid Dispensers Board

Do not use this form for:

California BRN CEs: An alternate process was adopted in Aug 2022. Contact justin.dauterman@sfdph.org for more information.
California Department of Public Health (CDPH) CEs for Certified Nursing Assistants. ZSFG DET is currently not an approved provider for these CEs.

Documents required with this online application include:

Announcement/flyer publicizing the course must contain:
- course title and description;
- date, time, and location;
- target audience;
- registration and contact information;
- specific approval statements required by the regulating Board (identified in Course Details below);
- and organization's cancellation policy (identified in Course Details section below).
Teaching/presentation materials such as:
- agenda;
- syllabus/outline;
- handouts and tests template (if applicable); and
- evaluation template.
Instructor(s)' Curriculum Vitae/resume
Presenter(s)' Disclosure of Financial Interest (see Template Resources below)
If seeking approval from Physical Therapy Board of California:
- Download the application and requirement guideline for Physical Therapy Board of California and Speech-Language Pathology, Audiology and Hearing Aids Dispensers Board and assure that you meet all the requirements for approval.
- Attach the additional application form found within this document and all other requirements with this online application.

Late and/or incomplete applications will not be approved. Course approval is required prior to advertising a course. For Board of Registered Nursing approval, adverstising while under the review process requires the following statement on you announcement/flyer "Continuing education credit approval pending."

Template Resources may be downloaded, utilized and modified as appropriate without removing the required elements (update coming soon):

Continuing Education Planner and Presenter Disclosure Form: this is included in this online application form. However, utilize this downloadable form if you need a vendor to complete this requirement. Attach the vendor-completed disclosure form with this online application
Announcement/flyer
Evaluation
Self-Study & Web-based Course Outline is required for Self-Study and Web-based course types
Attendance: if the course is approved, this attendance form is required and should be submitted within 2 weeks after course completion

For any questions or concerns, please send an email to the DET Manager, Justin Dauterman, MSN, RN, NPD-BC (justin.dauterman@sfdph.org 628-206-4171)

Main Contact *

First Name Last Name

Name of your organization & division *

E-mail *

Phone Number *

Area Code Phone Number

Select the Board approval you intend to apply for and note the application due date *

Emergency Medical Services Agency (EMT/EMT-P) - Application due 2-3 weeks before the course Physical Therapy Board of California - Application due 30 days before the course Speech-Language Pathology, Audiology and Hearing Aid Dispensers Board - Application due 30 days before the course

Will this course be uploaded to Halogen Learning Management System? *

Yes No N/A: Non-DPH applicant

Will this course be advertised outside of one care unit/department? *

Yes No Non-ZSFG applicant

Select the course type *

In-person/face-to-face Web-based Self-study

Number of theory/didactic hours requested *

1 theory/didactic hour = 1 CE contact hour. Courses less than 50 minutes will not be approved

Number of clinical practice hours requested *

3 clinical practice/skills hours = 1 CE contact hour

How many days of attendance is required to receive CE credits? *

Identify the date(s) your course will be offered *

Course Title *

As it will appear on the CE certificate and Halogen (if applicable)

Detailed course description *

Detailed learning objectives (at least 2 for each topic in the agenda) *

Upload Announcement/flyer

Upload a File

Reminder: An announcement/flyer requires the following elements:

Course title, description, and learning objectives
Date, time, and location of course
Target Audience
Registration/contact information
Additional elements required for Physical Therapy Board of California and Speech-Language Pathology, Audiology and Hearing Aid Dispensers Board approval
- Program schedule
- Speaker names, titles, and qualifications
- Type of instructional method(s) (lecture only, lecture w/demonstration, lecture w/hands-on/technique lab)
- Student-to-faculty ratio (only necessary if course contains hands-on/technique lab
An approval statement that includes the name of approval agency/continuing education provider, its identification number, and the number of contact hours it is approved for:

This course is approved for __ CE contact hour(s) by San Francisco General Hospital Nursing Services, an approved continuing education provider by the {Physical Therapy Board of California} OR {Speech-Language Pathology, Audiology and Hearing Aid Dispensers Board (PDP# 204)}.

Cancellation policy:

Cancellation Policy: An attendee-initiated cancellation at 10-days or more before the class date is entitled for a full refund or a
voucher applicable towards a future class; a cancellation less
than 10 days before the class date is not entitled for a refund or
voucher. A department-initiated cancellation entitles the attendee
for a full refund or voucher towards a future class. These terms do
not apply to free courses.

Upload agenda, syllabus/outline, evaluation template, & PT/Speech application *

Upload a File

Upload teaching/presentation materials, handouts, and test *

Upload a File

Course Instructor(s)

Instructor(s) Curriculum Vitae/Resume *

Upload File(s)

Multiple files may be uploaded in this field

Instructor(s) Curriculum Vitae/Resume

Upload File(s)

Multiple files may be uploaded in this field

Vendor-completed disclosure form

Attach a vendor-completed disclosure form to satisfy this requirement

Upload Disclosure form completed by a vendor

Name

First Name Last Name

Role

Planner/Facilitator Presenter/Faculty

Acknowledge understanding

This disclosure is for a single-activity and only discloses information during the past 12 months from the activity or course date. Any change in information before the actual course date will be reported to the planner/facilitator.

This continuing education disclosure form is to assist in identifying and resolving any potential conflicts of interest. A conflict of interest exist when an individual has a financial relationship with a commercial interest and has the chance to affect the educational content related to that commercial interest. The goal is to maintain balance, independence, objectivity, and scientific accuracy of all educational offerings. Disclosed financial relationships with a commercial interest is not the basis for continuing education offerings approval. However, if you are not able to disclose any financial relationships for any reason, your activity or course will not be approved to offer continuing education credits. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Excluded from these are providers of clinical service directly to patients: non-profit or government agencies; non-health care related companies, liability and health insurance providers; group medical practices; for-profit hospitals; rehabilitation centers and nursing homes; blood banks; and diagnostic laboratories. Included into what needs to be disclosed are ownership of commercial interests, membership on boards of directors, trustees or advisory committees of commercial interests, grants or research support from commercial interests (excluding government, non-profit, or independent foundations), affiliate of commercial interests (including stock holder but not mutual fund holdings, employee/consultant, and member of speakers bureau).

Financial Relationship Disclosure

	Name of Commercial Interest	Type of Compensation (amount is NOT required)	My and/or Spouse/Parnter's Role

NO financial relationship with a commercial interest

Neither I nor my spouse/partner has any financial relationship with a commercial interest as identified in this disclosure

Signature

Please sign using your mouse Clear

Identify the areas, relevant to the target audience, this course intends to provide training or knowledge for. *

Patient-centered care/Clinical practice Practice-based learning and improvement System-based practice Evidence-based practice Nursing/Medical knowledge Quality Improvement Communication/Collaboration Professionalism/Ethics

Identify additional (if any) practice gaps and educational needs this course intends to address

Select a method to measure/determine the outcome of this course *

Learner evaluation (questions should aim to assess if objectives were met) Pre and Post-test Discussion of case-based studies Simulation/skills lab practice Observe adherence to practice guidelines/protocols Audience response/surveys

Course Core Curriculum, Lesson Plan, and Post-test *

Upload a File

Comments

Continuing Education Offerings Application

Continuing Education Offerings Application Process

Instructor/Facilitator's Information

Course Information

Course Details

Continuing Education Planner and Presenter Disclosure Form

Learning Needs Assessment