1 Start 2 Complete
*
YesNo
Are all components of the activity description complete?
Are the start and expiration dates consistent with the activity type?
Is the goal of the activity specific and measurable?
Note: only name and email of Faculty is required
*
YesNo
Identifies the professional practice gap (JAC 4)
Identifies the underlying educational need (JAC 4)
Identifies learning outcomes that are observable and measurable.
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.
Is the content evidence-based?
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.
*
*
YesNoNA
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)
Completed Conflict of Interest for all planning members and faculty.
Resolution or mitigation of any real or potential conflicts and confirmation that the activity is free of any commercial bias.
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.
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, providing an opportunity for learners to learn with, from, and about each other.
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.
Engagement of students of the health professions and patient/public representatives in the assessment, planning and delivery of continuing education activities when appropriate.
(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.
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.
Evaluation Methods
*
YesNo
Changes in skills, strategy, performance of one's role or contribution as a member of the healthcare team; and/or (JAC 8)
Impact on the healthcare team; and/or (JAC 11)
Impact on patient outcomes (JAC 11)
Conflict of interest and financial conflict (JAC 12)
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.
Calculating Hours
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.

Enter the total number of contact hour(s):
General requirements
YesNoNA
Are the contact hours calculation logical and defensible?
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?
Do the attached flyer, brochure, or marketing Materials contain the needed elements (Title, speaker, time, date, content narrative/objectives, accreditation statement)?
Does the planning table contain all required information?
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.
Implementation
Post Program Review
Post-Activity Checklist
YesNo
Evaluations summarized
Summary report saved on share drive
Summary report sent to Lead Facilitator
Date/Comments
YesNo
Review of evaluation measures with Lead Facilitator
Evaluation of planning process with Lead Facilitator
Date/Comments
YesNo
Changes made to activity based on evaluation data
If yes, list changes: