Planning Activity Checklist

Name of program *

Program Description

	Yes	No
Are all components of the activity description complete?	Are all components of the activity description complete? - Yes	Are all components of the activity description complete? - No
Are the start and expiration dates consistent with the activity type?	Are the start and expiration dates consistent with the activity type? - Yes	Are the start and expiration dates consistent with the activity type? - No
Is the goal of the activity specific and measurable?	Is the goal of the activity specific and measurable? - Yes	Is the goal of the activity specific and measurable? - No

Planning Team and Facilitators: is information complete for all Faculty?

Note: only name and email of Faculty is required

Yes

No

The educational design criteria ensure that activities are planned using evidence-based processes that are outcome driven. *

	Yes	No
Identifies the professional practice gap (JAC 4)	Identifies the professional practice gap (JAC 4) - Yes	Identifies the professional practice gap (JAC 4) - No
Identifies the underlying educational need (JAC 4)	Identifies the underlying educational need (JAC 4) - Yes	Identifies the underlying educational need (JAC 4) - No
Identifies learning outcomes that are observable and measurable.	Identifies learning outcomes that are observable and measurable. - Yes	Identifies learning outcomes that are observable and measurable. - No
The outcome addresses the educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap and achieving the learning outcome results in narrowing or closing the gap.	The outcome addresses the educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap and achieving the learning outcome results in narrowing or closing the gap. - Yes	The outcome addresses the educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap and achieving the learning outcome results in narrowing or closing the gap. - No
Is the content evidence-based?	Is the content evidence-based? - Yes	Is the content evidence-based? - No

Internal notes

Use this space to explain any comments in reference to the above answers. Be sure to copy and paste any notes that need to go back to the Activity Director/Lead Facilitator on the application itself in the “Requested Changes” text box.

What elements of adult learning are incorporated into this educational activity? (JAC 7) *

The planning process for all educational activities must demonstrate: *

	Yes	No	NA
An integrated planning process that includes 1) at a minimum: the JA planner, activity facilitator and a target audience representative. (The planner or facilitator may also represent the audience when appropriate.), 2) Frequency of planning meetings, 3) Personnel in planning meetings (content expert, target audience represented), 4) that the target audience is reflected. (JAC 6)	An integrated planning process that includes 1) at a minimum: the JA planner, activity facilitator and a target audience representative. (The planner or facilitator may also represent the audience when appropriate.), 2) Frequency of planning meetings, 3) Personnel in planning meetings (content expert, target audience represented), 4) that the target audience is reflected. (JAC 6) - Yes	An integrated planning process that includes 1) at a minimum: the JA planner, activity facilitator and a target audience representative. (The planner or facilitator may also represent the audience when appropriate.), 2) Frequency of planning meetings, 3) Personnel in planning meetings (content expert, target audience represented), 4) that the target audience is reflected. (JAC 6) - No	An integrated planning process that includes 1) at a minimum: the JA planner, activity facilitator and a target audience representative. (The planner or facilitator may also represent the audience when appropriate.), 2) Frequency of planning meetings, 3) Personnel in planning meetings (content expert, target audience represented), 4) that the target audience is reflected. (JAC 6) - NA
Completed Conflict of Interest for all planning members and faculty.	Completed Conflict of Interest for all planning members and faculty. - Yes	Completed Conflict of Interest for all planning members and faculty. - No	Completed Conflict of Interest for all planning members and faculty. - NA
Resolution or mitigation of any real or potential conflicts and confirmation that the activity is free of any commercial bias.	Resolution or mitigation of any real or potential conflicts and confirmation that the activity is free of any commercial bias. - Yes	Resolution or mitigation of any real or potential conflicts and confirmation that the activity is free of any commercial bias. - No	Resolution or mitigation of any real or potential conflicts and confirmation that the activity is free of any commercial bias. - NA
Addressing 1 or more of the competencies: Interprofessional Education Collaborative (IPEC), Quality and Safety Education for Nurses (QSEN), Institute of Medicine (IOM), and ACGME/ABMS, or other recognized competencies.	Addressing 1 or more of the competencies: Interprofessional Education Collaborative (IPEC), Quality and Safety Education for Nurses (QSEN), Institute of Medicine (IOM), and ACGME/ABMS, or other recognized competencies. - Yes	Addressing 1 or more of the competencies: Interprofessional Education Collaborative (IPEC), Quality and Safety Education for Nurses (QSEN), Institute of Medicine (IOM), and ACGME/ABMS, or other recognized competencies. - No	Addressing 1 or more of the competencies: Interprofessional Education Collaborative (IPEC), Quality and Safety Education for Nurses (QSEN), Institute of Medicine (IOM), and ACGME/ABMS, or other recognized competencies. - NA
If your activity is interprofessional, addressing 1 or more of the interprofessional competencies: 1) values/ ethics, 2) roles/responsibilities, 3) interprofessional communication, and/or 4) teams/teamwork.	If your activity is interprofessional, addressing 1 or more of the interprofessional competencies: 1) values/ ethics, 2) roles/responsibilities, 3) interprofessional communication, and/or 4) teams/teamwork. - Yes	If your activity is interprofessional, addressing 1 or more of the interprofessional competencies: 1) values/ ethics, 2) roles/responsibilities, 3) interprofessional communication, and/or 4) teams/teamwork. - No	If your activity is interprofessional, addressing 1 or more of the interprofessional competencies: 1) values/ ethics, 2) roles/responsibilities, 3) interprofessional communication, and/or 4) teams/teamwork. - NA
If your activity is interprofessional, providing an opportunity for learners to learn with, from, and about each other.	If your activity is interprofessional, providing an opportunity for learners to learn with, from, and about each other. - Yes	If your activity is interprofessional, providing an opportunity for learners to learn with, from, and about each other. - No	If your activity is interprofessional, providing an opportunity for learners to learn with, from, and about each other. - NA
An intent to achieve outcome(s) that reflects a change in skills, strategy, or performance of the professional, health care team and/or patient outcomes.	An intent to achieve outcome(s) that reflects a change in skills, strategy, or performance of the professional, health care team and/or patient outcomes. - Yes	An intent to achieve outcome(s) that reflects a change in skills, strategy, or performance of the professional, health care team and/or patient outcomes. - No	An intent to achieve outcome(s) that reflects a change in skills, strategy, or performance of the professional, health care team and/or patient outcomes. - NA
Engagement of students of the health professions and patient/public representatives in the assessment, planning and delivery of continuing education activities when appropriate.	Engagement of students of the health professions and patient/public representatives in the assessment, planning and delivery of continuing education activities when appropriate. - Yes	Engagement of students of the health professions and patient/public representatives in the assessment, planning and delivery of continuing education activities when appropriate. - No	Engagement of students of the health professions and patient/public representatives in the assessment, planning and delivery of continuing education activities when appropriate. - NA
(Optional and Best Practice) Using support strategies to sustain change as an adjunct to its educational interventions (e.g., reminders, patient feedback)? If yes, please describe below.	(Optional and Best Practice) Using support strategies to sustain change as an adjunct to its educational interventions (e.g., reminders, patient feedback)? If yes, please describe below. - Yes	(Optional and Best Practice) Using support strategies to sustain change as an adjunct to its educational interventions (e.g., reminders, patient feedback)? If yes, please describe below. - No	(Optional and Best Practice) Using support strategies to sustain change as an adjunct to its educational interventions (e.g., reminders, patient feedback)? If yes, please describe below. - NA

Internal notes

Use this space to explain any comments in reference to the above answers. Be sure to copy and paste any notes that need to go back to the Activity Director/Lead Facilitator on the application itself in the “Requested Changes” text box.

Do the activity evaluations seek to determine: *

	Yes	No
Changes in skills, strategy, performance of one's role or contribution as a member of the healthcare team; and/or (JAC 8)	Changes in skills, strategy, performance of one's role or contribution as a member of the healthcare team; and/or (JAC 8) - Yes	Changes in skills, strategy, performance of one's role or contribution as a member of the healthcare team; and/or (JAC 8) - No
Impact on the healthcare team; and/or (JAC 11)	Impact on the healthcare team; and/or (JAC 11) - Yes	Impact on the healthcare team; and/or (JAC 11) - No
Impact on patient outcomes (JAC 11)	Impact on patient outcomes (JAC 11) - Yes	Impact on patient outcomes (JAC 11) - No
Conflict of interest and financial conflict (JAC 12)	Conflict of interest and financial conflict (JAC 12) - Yes	Conflict of interest and financial conflict (JAC 12) - No

Internal notes

Use this space to explain any comments in reference to the above answers. Be sure to copy and paste any notes that need to go back to the Activity Director/Lead Facilitator on the application itself in the “Requested Changes” text box.

If Live:

Enter the total number of contact hour(s).

Total Minutes divided by 60= contact hour(s)
Note: Time spent evaluating the learning activity may be included in the total time when calculating contact hours.

If Enduring:

Enter the total number of contact hour(s):

Method of calculating contact hours:

Pilot Study

Historical Data

Complexity of Content

Other - Please describe:

General requirements

	Yes	No	NA
Are the contact hours calculation logical and defensible?	Are the contact hours calculation logical and defensible? - Yes	Are the contact hours calculation logical and defensible? - No	Are the contact hours calculation logical and defensible? - NA
Is an agenda attached for any activity over 2 hours and does it have appropriate breaks (at least every two hours) for the adult learners?	Is an agenda attached for any activity over 2 hours and does it have appropriate breaks (at least every two hours) for the adult learners? - Yes	Is an agenda attached for any activity over 2 hours and does it have appropriate breaks (at least every two hours) for the adult learners? - No	Is an agenda attached for any activity over 2 hours and does it have appropriate breaks (at least every two hours) for the adult learners? - NA
Do the attached flyer, brochure, or marketing Materials contain the needed elements (Title, speaker, time, date, content narrative/objectives, accreditation statement)?	Do the attached flyer, brochure, or marketing Materials contain the needed elements (Title, speaker, time, date, content narrative/objectives, accreditation statement)? - Yes	Do the attached flyer, brochure, or marketing Materials contain the needed elements (Title, speaker, time, date, content narrative/objectives, accreditation statement)? - No	Do the attached flyer, brochure, or marketing Materials contain the needed elements (Title, speaker, time, date, content narrative/objectives, accreditation statement)? - NA
Does the planning table contain all required information?	Does the planning table contain all required information? - Yes	Does the planning table contain all required information? - No	Does the planning table contain all required information? - NA

Internal notes

Use this space to explain any comments in reference to the above answers. Be sure to copy and paste any notes that need to go back to the Activity Director/Lead Facilitator on the application itself in the “Requested Changes” text box.

How will the number of participants be recorded by the planning team?

Sign–In Sheets

	Yes	No
Saved in file	Saved in file - Yes	Saved in file - No

Sign-In Sheet Date/Comments

Evaluations

	Yes	No
Evaluations summarized	Evaluations summarized - Yes	Evaluations summarized - No
Summary report saved on share drive	Summary report saved on share drive - Yes	Summary report saved on share drive - No
Summary report sent to Lead Facilitator	Summary report sent to Lead Facilitator - Yes	Summary report sent to Lead Facilitator - No

Evaluations Date/Comments

Date/Comments

Meeting

	Yes	No
Review of evaluation measures with Lead Facilitator	Review of evaluation measures with Lead Facilitator - Yes	Review of evaluation measures with Lead Facilitator - No
Evaluation of planning process with Lead Facilitator	Evaluation of planning process with Lead Facilitator - Yes	Evaluation of planning process with Lead Facilitator - No

Meeting Date/Comments

Date/Comments

Program Review

	Yes	No
Changes made to activity based on evaluation data	Changes made to activity based on evaluation data - Yes	Changes made to activity based on evaluation data - No

If yes, list changes:

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