INDIVIDUAL OFFERING APPROVAL FORM (IOA) CONTINUING NURSING EDUCATION RN/LPN This form must be completed in full and approval received BEFORE renewing your license. Please only submit ONE course per this IOA Form. Do not submit multiple courses on this form. Please make sure the course information attached matches the course on this form. Name KS Nursing License # Expiration Date (mm/dd/yyyy) Street Address City State Zip Code Telephone # Email Address CNE Course Title CNE Provider Name Course Completion Date CNE Provider Address Rationale Statement A brief explanation, in your own words, of why this offering is relevant Continuing Nursing Education for you. **Continuing Nursing Education is defined as “learning experiences intended to build upon the educational and experiential bases of the nurse for enhancement of practice, education, administration and research or theory development to the end of improving the health of the public.”** Learning Objectives Statements about what you learned and how the information will help in your practice as a nurse. Learning objectives are clear and measurable by use of an action verb that describes a measurable behavior. The verb should correspond with what opportunities were given to you as the participant, in order to demonstrate the nearly learned information. Examples of Verbs: Identify, List, Define, Describe, Locate, Discuss, Explain, Perform CNE AGENDA/SCHEDULE: Specific times of learning listed must be provided to verify the length of the offering. CERTIFICATE OF COMPLETION The Agenda/Schedule and the Certificates of Completion can be uploaded after clicking the submit button. Attestation I realize that this application is a legal document and by pressing the Submit button I am declaring under penalty of perjury under the laws of the State of Kansas that the information I have provided is true and correct to the best of my knowledge. If all the above information is correct please press the Submit button . Otherwise please go back and correct any information that is necessary. SUBMIT WILL CONTINUE YOU ON TO THE FILE UPLOAD PAGE
