REQUEST TO ASSIGN OR UPDATE FORM
SECTION 1
: CONTENT OWNER
Company
:
Please select...
Bon Secours Charity Health System Medical Group, P.C.
Bon Secours Community Hospital
Good Samaritan Hospital of Suffern, N.Y.
HealthAlliance Hospital, Broadway Campus
HealthAlliance Hospital, Marys Avenue Campus
Margaretville Memorial Hospital
Mid-Hudson Valley StaffCo
Mountainside Residential Care Center
NorthEast Provider Solutions
Schervier Pavilion
St. Anthony Community Hospital
Westchester Medical Center
Westchester Medical Center Advanced Physician Services, P.C.
Select more than one company by holding down the CTRL button on your keyboard and then clicking on your selections using your mouse.
Department
:
Primary Contact Owner Name
:
Primary Contact Phone Number
:
Primary Contact Email
:
SECTION 2
: TABLE OF CONTENTS
Please answer the following questions and attach documents where applicable:
Course Title:
Course description and learning objectives:
Course Type:
New Course
Revised Course
Assign Existing Course to New Learners
Upload Method of Instruction (Video/Slides/Audio):
Indicate Method of Evaluation:
Quiz
Attestation
Provide Test Document in Word with correct answers in
bold
or highlighted:
Hyperlinks or embedded videos are included in this program.
Yes
No
If applicable, indicate the regulatory agency and/or accrediting organization:
DNV
AACN
DHHS
HIPAA
CMS
OSHA
ACR
OIG
Homeland Security/FEMA
Other
Other (please indicate):
SECTION 3
: ASSIGNMENT AND REVIEW
Target Learners (Organization, Department, Job Titles)
:
Course Assignment
:
Mandatory
Elective
Course Frequency
:
One-time
Annual
Requested Start Date
:
Requested Completion Date
:
SECTION 3
: OUTCOME MEASUREMENT
Level 1
:
Reaction
: How the learners felt about the training or learning experience.
Level 2
:
Learning
:
Measurement
of increase in knowledge or capability.
Level 3
:
Behavior
: The
measurement
of capability improvement and
applied
learning
/implementation on the job.
Level 4
:
Results
: The effects/impact on services resulting from the trainee's performance.
Return on Investment
: Performance measures to evaluate financial
efficiencies
gained through the cost of the educational initiative.
Indicate with an (X)
all levels
of outcome measurement the Content Owner will evaluate
:
Level 1 - Reaction
Level 2 - Learning
Level 3 - Behavior
Level 4 - Results
ROI - Return on Investment
SECTION 4
: SIGNATURE
Content Owner Electronic Signature:
WORKFORCE DEVELOPMENT USE ONLY
Reviewer Name:
Reviewed By:
Decision for Reviewer:
Accept
Missing Document(s)
Comments:
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.