Activity Planning Submission Complete this form in its entirety.Step 1 of 812%Course Title*Presenter / Author Name* First Last Description of the Target Audience* PT / PTA (Physical Therapist / Physical Therapist Assistant) OT / OTA (Occupational Therapist / Occupational Therapist Assistant) SLP (Speech Language Pathologist) ATC (Certified Athletic Trainer) MT / LMT (Massage Therapist / Licensed Massage Therapist) RN (Registered Nurse) LVN / LPN (Licensed Vocational Nurse / Licensed Practical Nurse) CNA (Certified Nursing Assistant) NHA (Nursing Home Administrator) RT (Respiratory Therapist) LMSW / LCSW (Licensed Master Social Work / Licensed Clinical Social Worker) RD / RDN / LD (Registered Dietitian / Registered Dietitian Nutritionist / Licensed Dietitian) Activities ProfessionalList Nursing Specialities*Separate specialties with a commaEducational PlanningSkill Level*BeginnerIntermediateAdvancedIdentified Gap(s)*Indicate the issues, problems, and/or practice gaps you want to address.Description of Current State*Describe the specific issues, problems, and/or practice gaps indicated above.Description of Desired/Achievable State*What will the learners be expected to do differently as a result of their participation in this activity that addresses the practice gaps above?Anticipated Length of Course*1 Hour2 Hours3 Hours4 Hours5 Hours6 HoursEducational Planning (Continued)Hour 1 (60 minutes) - Content Description (Topics covered within the first 60 minutes of the presentation.)*For example: • Respiratory system review • Breathing assessment • Recognizing a breathing emergency • Provide proper interventions in a respiratory emergency • Correct application and use of a BVMHow many learning objectives in Hour 1?*1234Hour 1 - 1st Learning Outcome - Will the student identify, locate, recognize or select?*For example: At the end of this course, the participant will IDENTIFY a respiratory emergency in patients.IdentifyLocateRecognizeSelectHour 1 - 1st Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 1 - 2nd Learning Outcome - Will the student identify, locate, recognize or select?*For example: At the end of this course, the participant will IDENTIFY a respiratory emergency in patients.IdentifyLocateRecognizeSelectHour 1 - 2nd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 1 - 3rd Learning Outcome - Will the student identify, locate, recognize or select?*For example: At the end of this course, the participant will IDENTIFY a respiratory emergency in patients.IdentifyLocateRecognizeSelectHour 1 - 3rd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 1 - 4th Learning Outcome - Will the student identify, locate, recognize or select?*For example: At the end of this course, the participant will IDENTIFY a respiratory emergency in patients.IdentifyLocateRecognizeSelectHour 1 - 4th Learning Outcome*For example: Identify a respiratory emergency in patients.Instructional Materials Used in Hour 1 (select all that apply)* Demonstration Video Course Manual / SlidesHour 2 (60 minutes) - Content Description (Topics covered within the second hour of the presentation.)*For example: • Respiratory system review • Breathing assessment • Recognizing a breathing emergency • Provide proper interventions in a respiratory emergency • Correct application and use of a BVMHow many learning objectives in Hour 2?*1234Hour 2 - 1st Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 2 - 1st Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 2 - 2nd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 2 - 2nd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 2 - 3rd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 2 - 3rd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 2 - 4th Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 2 - 4th Learning Outcome*For example: Identify a respiratory emergency in patients.Instructional Materials Used in Hour 2 (select all that apply)* Demonstration Video Course Manual / SlidesHour 3 (60 minutes) - Content Description (Topics covered within the third hour of the presentation.)*For example: • Respiratory system review • Breathing assessment • Recognizing a breathing emergency • Provide proper interventions in a respiratory emergency • Correct application and use of a BVMHow many learning objectives in Hour 3?*1234Hour 3 - 1st Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 3 - 1st Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 3 - 2nd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 3 - 2nd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 3 - 3rd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 3 - 3rd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 3 - 4th Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 3 - 4th Learning Outcome*For example: Identify a respiratory emergency in patients.Instructional Materials Used in Hour 3 (select all that apply)* Demonstration Video Course Manual / SlidesHour 4 (60 minutes) - Content Description (Topics covered within the fourth hour of the presentation.)*For example: • Respiratory system review • Breathing assessment • Recognizing a breathing emergency • Provide proper interventions in a respiratory emergency • Correct application and use of a BVMHow many learning objectives in Hour 4?*1234Hour 4 - 1st Learning Outcome - Will the student identify, list, or recognize?*IdentifyLocateRecognizeSelectHour 4 - 1st Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 4 - 2nd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 4 - 2nd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 4 - 3rd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 4 - 3rd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 4 - 4th Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 4 - 4th Learning Outcome*For example: Identify a respiratory emergency in patients.Instructional Materials Used in Hour 4 (select all that apply)* Demonstration Video Course Manual / SlidesHour 5 (60 minutes) - Content Description (Topics covered within the fifth hour of the presentation.)*For example: • Respiratory system review • Breathing assessment • Recognizing a breathing emergency • Provide proper interventions in a respiratory emergency • Correct application and use of a BVMHow many learning objectives in Hour 5?*1234Hour 5 - 1st Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 5 - 1st Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 5 - 2nd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 5 - 2nd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 5 - 3rd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 5 - 3rd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 5 - 4th Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 5 - 4th Learning Outcome*For example: Identify a respiratory emergency in patients.Instructional Materials Used in Hour 5 (select all that apply)* Demonstration Video Course Manual / SlidesHour 6 (60 minutes) - Content Description (Topics covered within the sixth hour of the presentation.)*For example: • Respiratory system review • Breathing assessment • Recognizing a breathing emergency • Provide proper interventions in a respiratory emergency • Correct application and use of a BVMHow many learning objectives in Hour 6?*1234Hour 6 - 1st Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 6 - 1st Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 6 - 2nd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 6 - 2nd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 6 - 3rd Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 6 - 3rd Learning Outcome*For example: Identify a respiratory emergency in patients.Hour 6 - 4th Learning Outcome - Will the student identify, locate, recognize or select?*IdentifyLocateRecognizeSelectHour 6 - 4th Learning Outcome*For example: Identify a respiratory emergency in patients.Instructional Materials Used in Hour 6 (select all that apply)* Demonstration Video Course Manual / SlidesEvidence Based ReferencesDo you have a minimum of 5 peer reviewed journal references dated within the last 5 years?*YesNoYou must have a minimum of 5 peer reviewed journal references dated within the last 5 years!Total number of references?*56789101112131415161718192021222324252627282930Reference #1*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #1 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #2*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #2 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #3*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #3 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #4*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #4 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #5*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #5 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #6*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #6 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #7*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #7 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #8*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #8 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #9*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #9 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #10*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #10 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #11*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #11 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #12*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #12 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #13*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #13 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #14*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #14 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #15*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #15 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #16*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #16 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #17*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #17 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #18*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #18 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #19*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #19 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #20*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #20 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #21*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #21 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #22*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #22 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #23*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #23 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #24*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #24 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #25*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #25 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #26*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #26 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #27*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #27 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #28*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #28 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #29*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #29 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsiteReference #30*All references must be written in APA format. To format your references automatically, try using http://www.citationmachine.net/.Is reference #30 a book, journal, peer-reviewed journal, or website?*BookJournalPeer-Reviewed JournalWebsitePost-Course ExamDo you have a minimum of 5 questions per course hour (i.e. a 2-hour course requires at least 10 questions)?*YesNoYou must have at least 5 questions per course hour!You must have at least one exam question for every course objective (learning outcome). Do you have at least one exam question for each objective?*YesNoYou must have at least one exam question for each course objective!Exam question #1 with answer choices; denote the correct answer.*For example: Which of the following reflexes are tested when assessing the shoulder? A. Biceps B. Triceps C. Pectoralis major D. All of the above (*correct answer)Which PowerPoint slide(s) includes the correct answer for exam question #1?*For example: Slide 12: Testing Shoulder ReflexesWhich course objective (learning outcome) does exam question #1 refer to?*For example: Objective #12 - Identify special tests for anterior shoulder instability.Exam question #2 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #2?*Which course objective (learning outcome) does exam question #2 refer to?*Exam question #3 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #3?*Which course objective (learning outcome) does exam question #3 refer to?*Exam question #4 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #4?*Which course objective (learning outcome) does exam question #4 refer to?*Exam question #5 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #5?*Which course objective (learning outcome) does exam question #5 refer to?*Exam question #6 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #6?*Which course objective (learning outcome) does exam question #6 refer to?*Exam question #7 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #7?*Which course objective (learning outcome) does exam question #7 refer to?*Exam question #8 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #8?*Which course objective (learning outcome) does exam question #8 refer to?*Exam question #9 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #9?*Which course objective (learning outcome) does exam question #9 refer to?*Exam question #10 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #10?*Which course objective (learning outcome) does exam question #10 refer to?*Exam question #11 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #11?*Which course objective (learning outcome) does exam question #11 refer to?*Exam question #12 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #12?*Which course objective (learning outcome) does exam question #12 refer to?*Exam question #13 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #13?*Which course objective (learning outcome) does exam question #13 refer to?*Exam question #14 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #14?*Which course objective (learning outcome) does exam question #14 refer to?*Exam question #15 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #15?*Which course objective (learning outcome) does exam question #15 refer to?*Exam question #16 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #16?*Which course objective (learning outcome) does exam question #16 refer to?*Exam question #17 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #17?*Which course objective (learning outcome) does exam question #17 refer to?*Exam question #18 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #18?*Which course objective (learning outcome) does exam question #18 refer to?*Exam question #19 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #19?*Which course objective (learning outcome) does exam question #19 refer to?*Exam question #20 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #20?*Which course objective (learning outcome) does exam question #20 refer to?*Exam question #21 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #21?*Which course objective (learning outcome) does exam question #21 refer to?*Exam question #22 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #22?*Which course objective (learning outcome) does exam question #22 refer to?*Exam question #23 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #23?*Which course objective (learning outcome) does exam question #23 refer to?*Exam question #24 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #24?*Which course objective (learning outcome) does exam question #24 refer to?*Exam question #25 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #25?*Which course objective (learning outcome) does exam question #25 refer to?*Exam question #26 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #26?*Which course objective (learning outcome) does exam question #26 refer to?*Exam question #27 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #27?*Which course objective (learning outcome) does exam question #27 refer to?*Exam question #28 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #28?*Which course objective (learning outcome) does exam question #28 refer to?*Exam question #29 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #29?*Which course objective (learning outcome) does exam question #29 refer to?*Exam question #30 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for exam question #30?*Which course objective (learning outcome) does exam question #30 refer to?*Post-Course Exam (Continued)Do you have additional exam questions?*YesNoTotal number of additional exam questions?*12345678910Additional exam question #1 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #1?*Which course objective (learning outcome) does additional exam question #1 refer to?*Additional exam question #2 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #2?*Which course objective (learning outcome) does additional exam question #2 refer to?*Additional exam question #3 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #3?*Which course objective (learning outcome) does additional exam question #3 refer to?*Additional exam question #4 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #4?*Which course objective (learning outcome) does additional exam question #4 refer to?*Additional exam question #5 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #5?*Which course objective (learning outcome) does additional exam question #5 refer to?*Additional exam question #6 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #6?*Which course objective (learning outcome) does additional exam question #6 refer to?*Additional exam question #7 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #7?*Which course objective (learning outcome) does additional exam question #7 refer to?*Additional exam question #8 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #8?*Which course objective (learning outcome) does additional exam question #8 refer to?*Additional exam question #9 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #9?*Which course objective (learning outcome) does additional exam question #9 refer to?*Additional exam question #10 with answer choices; denote the correct answer.*Which PowerPoint slide(s) includes the correct answer for additional exam question #10?*Which course objective (learning outcome) does additional exam question #10 refer to?*Author / Speaker BiographySpeaker Biography*Please write a short biography. This will be displayed for prospective course buyers so that they may learn more about you and your expertise. Your biography should be written in paragraph format and include educational background and demonstrate your clinical / specialty expertise. Your biography should be no longer than 2 paragraphs.Sample biography: Adina Soclof, a certified Speech Pathologist, received her master’s degree from Hunter College in New York in Communication Sciences. Adina worked as a Speech Pathologist in preschools for the developmentally disabled in the New York area before staying home full time with her family. Adina re-entered the workforce as a Parent Educator for Bellefaire Jewish Children's Bureau facilitating "How to Talk so Kids will Listen and Listen so Kids will Talk" workshops as well as workshops based on “Siblings Without Rivalry” and "Raising a Spirited Child". She has been featured at numerous nonprofit organizations and private schools in Cleveland. Adina developed TEAM Communication Ventures and conducts parenting, teacher and clinician workshops via telephone nationwide.Course DescriptionCourse Description*Your description should outline the problem that your course aims to solve. The title and description provide a great opportunity to let potential buyers know what your course is all about. They are the tool potential buyers use to make the decision to purchase your course. A great description hits the clinical high-points, presents the problem to be addressed through the course, why it is important, and how the course will address the problem.Biographical Conflict of InterestTitle of Educational Activity (Course Title)*Educational Activity Date (Today's Date)* MM slash DD slash YYYY Role in Educational Activity*Select all that apply. Nurse Planner Content Expert Faculty/Presenter/Author Content Reviewer OtherOther Role in Educational Activity:*Your Name* First Last Credentials*Degrees*Select all that apply. Diploma AD BSN Masters Doctorate OtherOther Degree(s):*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Current Employer and Position/Title*Expertise*Please describe expertise specific to the educational activity.You are here: Home / Activity Planning Submission