Please answer the questions below.

We will also need the following information:

a. One copy of the certificate that was given to the learner on the date of the event.

Click here to upload these documents.

Assigned ONA Application #

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* 1. Assigned ONA Application #

Title of activity.

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* 2. Title of activity.

Name of organization/applicant.

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* 3. Name of organization/applicant.

Date this activity was held.

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* 4. Date this activity was held.

What was the city and state that this program was offered?

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* 5. What was the city and state that this program was offered?

What was your target audience (RN, LPN, Interprofessional)?

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* 6. What was your target audience (RN, LPN, Interprofessional)?

Total number of participants.

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* 7. Total number of participants.

Enter total number of contact hours offered upon completion.

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* 8. Enter total number of contact hours offered upon completion.

Was this activity jointly provided?

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* 9. Was this activity jointly provided?

Did this activity receive commercial support?

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* 10. Did this activity receive commercial support?

Amount of commercial support.

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* 11. Amount of commercial support.

What changes will you make based on evaluation by learners of the activity? (Even if your program will only be presented one time, please answer this question as if it were being repeated).

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* 12. What changes will you make based on evaluation by learners of the activity? (Even if your program will only be presented one time, please answer this question as if it were being repeated).

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