CLASS REQUEST FORM Please complete this form and email it to [email protected]. Allow three weeks for proc Complete this form in its entirety for processing. Incomplete forms slow the processing t This shaded area is for office use only Class Number Time: Today's Date: TM: Mayor Type of Activity: Territory #: 855 Date of activity: Feb 13th, 2007 Instructor: Nadine Nakazawa, RN # of Participants: 15 Registration Fee: $150.00 All piccs / power too Different Charge TM Address: 1535 Vista Club Cr, #205 City, State, Zip: Santa Clara, CA 95054 Free Participants: TM Extension: Account Info: Shipping Info: (select one option) Attention HUSI/SHAD#: Facility Address City, ST, Zip Facility Information Contact Information Name: Stanford Center for Education Name: Nadine Nakazawa Address: 1451 S. California Av Title: Picc nurse ty, State Zipcode: Palo Alto, CA Depart.: Phone: Fax: Other: Do you want a flyer: Products Requested: Please type the product code(s) of the needed kits 1 Full Groshong 3 5 2 Full power picc 4 6 You will need: Would you like to have the new Educational Brochure sent to the Class? Additional Information Please fill out this portion as necessary Flyer Information: Indicate any particular information that you would like incorporated in the flyer for this activity (i.e.: directions, special instructions, room number, etc.) Any additional Information: This is not a standard Picc class it is an educaiton and re-training class with A.A. for the morning group a 7 ea full power picc, 5 fr single is fine, 7 ea. full Groshong tray. New Existing Competitive Ship to TM Ship to the activi Ship to alternate locatio Yes No One kit per partic One kit per every two Yes No Basic Groshon Basic Per-Q-C Neonatal Gros Neonatal Per- Advanced Full Advanced Half Inservice-Saf Precepting - SiteRite Miscellanous
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CLASS REQUEST FORMPlease complete this form and email it to [email protected]. Allow three weeks for processing.
Complete this form in its entirety for processing. Incomplete forms slow the processing time.This shaded area is for office use only
Class Number Time: Today's Date:
TM: Mayor Type of Activity:
Territory #: 855
Date of activity: Feb 13th, 2007
Instructor: Nadine Nakazawa, RN
# of Participants: 15
Registration Fee: $150.00 All piccs / power too
Different Charge TM Address: 1535 Vista Club Cr, #205City, State, Zip: Santa Clara, CA 95054
Free Participants: TM Extension:
Account Info: Shipping Info:(select one option)
Attention
HUSI/SHAD#: Facility
Address
City, ST, Zip
Facility Information Contact InformationName: Stanford Center for Education Name: Nadine Nakazawa
Address: 1451 S. California Av Title: Picc nurseCity, State Zipcode: Palo Alto, CA Depart.:
Phone:Fax:
Other:
Do you want a flyer:
Products Requested: Please type the product code(s) of the needed kits1 Full Groshong 3 52 Full power picc 4 6
You will need:
Would you like to have the new Educational Brochure sent to the Class?
Additional InformationPlease fill out this portion as necessary
Flyer Information: Indicate any particular information that you would like incorporated in the flyer for this activity (i.e.: directions,special instructions, room number, etc.)
Any additional Information: This is not a standard Picc class it is an educaiton and re-training class with A.A. for the morning group at Toledo Hospital7 ea full power picc, 5 fr single is fine, 7 ea. full Groshong tray.
To print flyer for class, please click on the
button which applies to you.
New
Existing
Competitive
Ship to TM
Ship to the activity location
Ship to alternate location - indicate below
Yes No
One kit per participant One kit per every two participant
If applicable: please indicate if there will be a different charge for some of the attendees.
A23
If applicable: please indicate how many participants will attend the activity for free.
Justification FormEducational Opportunities - Product Sales Growth Tracking form
Please note that this portion is mandatory for the completion of any educational activity.
Customer ID#:
Product Number Current Monthly Anticipated Actual Sales Actual Sales GrowthActual Sales Monthly Growth % 3 months after 6 months after during measurement
Educational Activity Educational Activity period %Units Dollars Percentage Units Dollars Units Dollars Percentage
The growth measured here may be accounted for by the educational opportunity, or may be only a small portion of many factorsthat influenced growth during the time period measured. Please take a few minutes to explain why this educational activity is
important to you and your account. Your comments will be used when making decisions about future educational opportunities.
Any participants from other facilities at this educational activity?
How will this educational activity affect their facility? Retrain additional nurses for Picc team
Yes No
Cost Tracking Form for Basic Groshong Classes
TM: Number of Participants:Date of Class: Registration Fee:
Instructor: Different Fee:
Sec A) Item and Description: Quantity Required Price Total(enter values here)
Discount fee by 20% if you belong to UNA, include a copy of your UNA Membership Card
insufficient registration.
This program is approved by the Utah Nurses Association as an approver of the Continuing Education for nursing by
the American Nurses Credentialing Center Commission on Accreditation. This
course has been approved for 9.9 contact hours.
“Vascular Access New Technology for Advanced
Practice ”A Nine Hour Interactive Workshop
Awarding 9.9 CEU Credits
A workshop designed for the experienced vascular access clinician who wants to implement advanced insertion
techniques.
Please mail fee & registration to:
Bard Access SystemsSteve Sigl
521 Columbia Cr DrSan Ramon, CA. 94582
Workshop Information About the Instructor
Date: Feb 13th, 2007
Time:
TM: Mayor
Location: Stanford Center for Education
1451 S. California Av
Palo Alto, CA
Fee: $150.00
Program Schedule Refund Policy7:30-7:45 am Registration
7:45-8:00 am Welcome/Introduction
8:00-8:15 am
8:15-9:15 am
9:15-9:30 am
9:30-9:45 am Break Target Audience9:45-10:15 am Case Studies
10:15-11:00 am
11:00-11:15 am
11:15-11:45 am The Program
11:45-1:00 pm Lunch
1:00-1:30 noon
1:30-1:45 pm
1:45-2:15 pm Completion Requirements
2:15-3:00 pm Break
3:00-3:15 pm Ultrasound Basics
3:15-3:30 pm Capital Equipment CostJustification 1. Attends the ENTIRE workshop3:30-4:00 pm Site~Rite Ultrasound Use and Tips 2. Completes the practicum4:00-4:15 pm 3. Returns a completed course evaluation form
4. Pays appropriate fees4:15-5:45 pm Practicum
5:45-6:00 pm Course Evaluation
The participant will be able to demonstrate MicroIntroducer insertion technique competence on an anatomical model in a laboratory skills practicum
Nadine Nakazawa, RN, CRNI has been a picc nurse at Stanford University Medical center for
over 15 year. She has been a picc instructor for over 10 years and has been on the foreftont of
many picc development innovations.
Limited class size and open discussion facilitated by the instructor promotes continuous interaction between faculty and participants. Participants should dress comfortably, relax and enjoy this unique learning
experience.
NOTE: The workshop begins promptly at 7:45 am. Late arrivals may attend the remainder of the workshop but will NOT receive a certificate of
completion.
This program meets the following objectives:
The student will be able to define an early vascular access assessment program. Tuition will be refunded (less a $10.00 processing fee) if
notification is received no later than 7 days prior to the workshop. Notification may be verbal or in writing. Participants may also
elect to send another person in their place.
The student will be able to articulate an understanding of reactive versus proactive IV therapy.
Defining a Vascular Access Early Assessment Program
The student will be able to review case studies and determine the correct vascular access device based on DRG, LOS, or drug therapy.
Reactive Versus Proactive IV TherapyVAD Selection by Diagnosis/LOS/Drug Therapy
The student will be able to articulate an understanding of ultrasound basics.
Appropriate participants include those who have previously attended and successfully completed a thorough basic PICC
workshop followed by extensive clinical experience in the insertion, use and maintenance of these devices.
The student will be able to articulate the basic functions of a portable ultrasound unit.
Implementation of the Assessment Advantage Program
The student will be able to articulate the steps used when incorporating portable ultrasound for inserting a PICC.
Advantages/Disadvantages of the MicroIntroducer insertion technique
The participant will be able to demonstrate portable ultrasound competence on an anatomical model in a laboratory skills practicum.
Troubleshooting the MicroIntroducer Insertion Technique
The program instructors bring to you their experiences of hundreds of PICC/Midline insertions along with the vast
experience of Bard Access Systems, which encompasses thousands of catheter placements throughout the world.The student will be able to define advantages of using the
MicroIntroducer technique for gaining peripheral venous access.Potential Complication Management
MicroIntroducer insertion cost Justification
The student will be able to list disadvantages of using the MicroIntroducer technique for gaining peripheral venous access.
MicroIntroducer Insertion Technique Demonstration
Certificates of completion will be issued at the end of the workshop providing the participant has met the following
requirements.The student will be able to demonstrate techniques for overcoming difficulties during use of the MicroIntroducer insertion technique.
The student will be able to articulate the potential complications associated with the MicroIntroducer insertion technique along with the nursing interventions for each potential complication.
Vascular Access with Site~Rite Ultrasound System
Advanced Half-day Registration
Advanced Half-day RegistrationName:
Address:
City:
State:
Zip Code:
Daytime Phone ( ) -
Professional License #:
Employer:
Fee Enclosed:
Please mail fee & registration to:
Bard Access SystemsMayor
1535 Vista Club Cr, #205Santa Clara, CA 95054
Program Approval
Discount fee by 20% if you belong to UNA, include a copy of your UNA Membership Card
We reserve the right to cancel the workshop due to insufficient registration.
This program is approved by the Utah Nurses Association as an approver of the Continuing
Education for nursing by the American Nurses Credentialing Center Commission on Accreditation.
This course has been approved for 3.3 contact hours per section.
A workshop designed for the experienced vascular access clinician who wants to begin using the MicroIntroduction
insertion technique.
PICC and Midline Catheter Vascular Access Using The
MicroIntroducer Technique
Half-day Workshop Information
Feb 13th, 2007 Program Schedule About the Instructor
Stanford Center for Education 7:30-8:00 am Registration
0
1451 S. California Av 8:00-8:05 am Welcome/Introduction
Palo Alto, CA 8:05-8:15 am
8:15-8:45 am
Fee $100.008:45-9:15 am Potential Complication Management
9:15-9:30 am Cost Justification
9:30-10:00 am
TM 10:00-10:45 am Practicum
1-800-443-3398 ext. 0000 10:45-11:00 am Course Evaluation Refund Pollicy
Target Audience
The Program
Completion Requirements
1. Attends the ENTIRE workshop2. Completes the practicum3. Returns a completed course evaluation form
Advantages/Disadvantages of the MicroIntroducer Insertion Technique
Troubleshooting the MicroIntroducer Insertion Technique
For further information on this offering please call: MicroIntroducer Insertion Technique
Demonstration
Tuition will be refunded (less a $10.00 processing fee) if notification is received no later than 7 days prior to the workshop. Notification may be
verbal or in writing. Participants may also elect to send another person in their place.
This program meets the following objectives:
NOTE: The workshop begins promptly at 8:00 am. Late arrivals may attend the remainder of the workshop but will NOT receive a certificate
of completion.
The student will be able to list five factors that may negatively influence their ability to obtain peripheral venous access in the standard fashion.
The student will be able to define advantages of using the MicroIntroducer technique for gaining peripheral venous access.
The student will be able to list disadvantages of using the MicroIntroducer technique for gaining peripheral venous access.
Appropriate participants include those who have previously attended and successfully completed a thorough basic PICC workshop followed by extensive clinical experience in the insertion, use and maintenance of
these devices.The student will be able to demonstrate techniques for overcoming difficulties during use of the MicroIntroducer insertion technique.
The student will be able to articulate the potential complications associated with the MicroIntroducer insertion technique along with the nursing interventions for each potential complication.
Students will be able to accurately complete the cost justification worksheet, representing their individual facility circumstances.
The program instructors bring to you their experiences of hundreds of PICC/Midline insertions along with the vast experience of Bard Access
Systems, which encompasses thousands of catheter placements throughout the world.
The student will be able to articulate the steps used in the MicroIntroducer insertion technique for inserting a PICC.
The participant will be able to demonstrate MicroIntroducer insertion technique competence on an anatomical model in a laboratory skills practicum
Certificates of completion will be issued at the end of the workshop providing the participant has met the following requirements.
Limited class size and open discussion facilitated by the instructor promotes continuous interaction between faculty and participants. Participants should dress comfortably, relax and enjoy this unique learning
experience.
4. Pays appropriate fees
Limited class size and open discussion facilitated by the instructor promotes continuous interaction between faculty and participants. Participants should dress comfortably, relax and enjoy this unique learning
NOTE: THE PURCHASE ORDER FORM MUST BE FILLED OUT AND INCLUDED IN THIS PACKET WHEN A PURCHASE ORDER NUMBER IS
PROVIDED AS METHOD OF PAYMENT.
Basic Groshong
Basic Per-Q-Cath
Basic Neonatal
Advanced
Safety Inservice
Miscellanous
ID #: 0Date: December 30, 1899TM: ='Activity Justification Form'!Q9Facility: 0
Workshop Reminders
1.
2.
3.
4. Return packets should include:
Attendance RecordsEvaluationsFee Reconciliation FormPayment of Registration Fees
Note:
Send all Packets to: Bard Access Systems
C/O Tina Uhrhan
5425 West Amelia Earhart Drive
Salt Lake City, Utah 84116
Thank You
Tina Uhrhan, Clinical Education Coordinator, 1-801-595-5406
Please remember that the proper documentation and the payment for you class needs to be sent to the Salt Lake City home office within one week following each class.
Use the return the Attendance Record. Make sure that the participants have completed the entire record.
Ensure all class participants have handed in the Evaluations. Evaluation forms can be found at the end of the Manual. Packets will be returned to the TM if evaluations are not included.
Certificates must be issued the day of the class. Recipients are responsible for keeping the certificates and Territory Managers should inform class participants that there is a $10.00 processing fee and 6-8 weeks processing time for duplicates.
P.O. form filled out in its entirety if class will be paid through a P.O by the facility
Future classes will not be scheduled for Territory Managers with late or incomplete packets.
Basic Registration
Name:
Address:
City:
State:
Zip Code:
Daytime Phone ( ) -
Professional License #:
Employer:
Fee Enclosed: 1
2
3
Please mail fee & registration to:4
Bard Access Systems5
Mayor1535 Vista Club Cr, #205
Santa Clara, CA 95054
1
2 Sterile technique refresher3
Program Approval
Provider approved by the California Board of Registered Nursing, Provider Number CEP 12028
for 10.2 contact hours.
The following didactic topics will be discussed to help clinicians choose the appropriate VAD for a
patient:
Indications and Contraindications for PICC and Midline Usage
We reserve the right to cancel the workshop due to insufficient registration.
Advantages and Disadvantages of PICC and Midline Usage
Advantages and Disadvantages of PICC and Midline Usage
Basic Anatomy and Physiology Review of the Veins of the Upper Arm, Chest and Central Venous System
Early Vascular Access Assessment Based on Diagnosis
In addition the following practicum topics will be discussed and demonstrated during a hands on insertion lab.
PICC and Midline insertion covering patient preparation, positioning, and placement technique
Discount fee by 20% if you belong to UNA – include a copy of your UNA Membership
Card PICC and Midline complication and care/maintenance management
This program is approved by the Utah Nurses Association as an approver of the Continuing Education for nursing by the American Nurses Credentialing Center Commission on Accreditation. This course work has been approved
for 10.2 contact hours.
An all day Interactive Workshop
Vascular Access DeviceInsertion Selection
& Management
Vascular Access DeviceInsertion Selection
& Management
Workshop Information Program Schedule About the InstructorFeb 13th, 2007
7:30 – 7:45 Registration
0
Stanford Center for Education 7:45 – 8:00 Welcome/Introduction
1451 S. California Av 8:00 – 9:00 Anatomy of the Arm/Chest
Palo Alto, CA Indications and
Contraindications of PICC &
Midlines
9:00 – 9:15 Physiology of bloodflow
9:15 – 9:30 Osmolality, Osmolarity, and drug pH
TM 9:30 – 9:45 Break
1-800-443-3398 9:45 – 10:15 Device selection & the cost of IV Therapy
11:15 – 12:15 Insertion procedure & video demonstration
12:15 – 1:15 Lunch
Describe PICC/Midline insertion competency guidleines1:15 – 2:15 Use and Maintenance
Target Audience
Define Peripherally inserted Central Catheters/Midlines.2:15 – 3:15 Complication Management
3:15 – 3:30 Break
3:30 – 4:00
The Program
Locate and select veins used for PICC/Midline insertion.4:00 – 6:00 Practicum
6:00 – 6:15 Evaluations
Completion Requirements
1. Attends the entire workshop2. Completes the practicum 3. Pays the appropriate fee
For further information on this offering please call:
This program meets the following objectives:
Tuition will be refunded (less a $10.00 processing fee) if notification is received no later than seven days prior to the workshop. Notification
may be verbal or in writing. Participants may also elect to send another person in their place.
This workshop targets the experienced IV clinician who wants to start inserting PICCs and Midlines. Although the primary focus of this workshop is for Registered Nurses, other healthcare professionals are welcome to attend. Educational contact hours will be awarded to RNs. This workshop also qualifies as a refresher course for those already inserting PICCs/Midlines.
Identify clinical indications for PICC/midlines placement using early assuessment protocol.
Identify patients who will benefit from PICC/Midline placement.
Identify methodologies for securing a physician's order for PICC/Midline insertion.
The program instructors bring their numerous experiences with PICC/Midline insertions along with the vast experience of Bard Access
Systems, which encompasses thousands of catheter placements throughout the world.Describe potential complications, prevention, and care
associated with PICC/Midline insertion and central venous access devise management.
Describe the correct stie care and maintenance protocols associated with PICCs/midlines
NOTE: The workshop begins promptly at 8:00 am. Late arrivals may attend the remainder of the workshop
but will NOT receive a certificate of completion.
Describe the importance of data collection and a quality management program. Certificates of completion will be issued at the end of the workshop
providing the participant has met the following requirements.Demonstrate insertion competency on an anatomical model in a laboratory skills practicum.
Type Date here
Nadine NakazawaPicc nurseStanford Center for Education1451 S. California AvPalo Alto, CA
Dear Nadine Nakazawa
Education Contact HoursCertification
Your Workshop has been scheduled for:
Date: Feb 13th, 2007Place: Stanford Center for EducationTime: 12:00 AMRegistration Fee: $150.00 Bard Territory Manager: Mayor
Supplies will be:#########
Enrollment:
Thank you for your interest in our Basic PICC and Midline Workshop. This letter is to confirm the date of the Workshop and to provide you with some information so that the Workshop runs smoothly and efficiently.
As host, please inform the participants before the Workshop (no later than the morning of the Workshop) of the following sections:
A minimum of 10 participants is required before a workshop will be provided. Please discuss attendance with the Territory manager, including the maximum number of attendees appropriate for this workshop. Please contact the Territory manager a minimum of seven (7) business days before the workshop with a final number of participants. This will ensure that a sufficient amount of materials will be available for the workshop.
Shipped to your Facility
Brought to the class by the Territory Manager
Educational Contact Hours:
Certification to Place PICCs and/or Midlines:
Materials for the Workshop:
Workbooks (one for every participant)PICC and/or Midline Product for the Practicum portion of the workshopPaperwork (attendance records, certificates of attendance, etc.)
Classroom Requirements:
10.2 contact hours will be provided to all RNs who attend the entire workshop. Partial credit cannot be given. It is approximately 8 hours of didactic information and a 2 hour practicum where participants practice simulated insertions on a model arm. Bard Access Systems does not allow live insertions to be performed during the workshops. Physicians, LPNs, etc. are welcome to attend the workshop, depending on your needs, but they will not receive educational contact hour credits.
It is the responsibility of the participant to keep the certificate of attendance for 4 years. If the certificate is lost, a duplicate copy can be obtained from Bard Access Systems after the participant’s attendance is confirmed. Processing time is two weeks.
Attending the Bard Access Systems workshop does not certify the RN to insert PICCs and/or Midlines. At this time, there is not a governing body that provides RN certification of PICC and/or Midline placement. Certification to insert PICCs and/or Midlines must be done by the RN’s employer. Only the employer can determine what “certification” means to a specific institution/agency. These criteria should be specified in the institution’s PICC/Midline Policy and Procedure. Your institution/agency must define what “certification” will be at your institution/agency.
You will be receiving the following workshop materials several days prior to the date of your workshop or the Bard Access Systems Territory manager will bring them the day of the workshop.
The Bard Access Systems Territory Manager will bring these items on the day of the workshop or have them shipped directly to you a few days before the workshop. If materials are being shipped to you, they will come in multiple boxes and deliveries. You will need to open all packages to assure that all items have arrived. If you are missing any of the above items, please contact the education department at 1-800-443-5505, ext. 4981, as soon as possible.
The classroom should be large enough o hold the expected number of participants in a comfortable classroom setting. The best set-up is classroom style with 6’ X 18 – 24” banquet tables with comfortable chairs. While we realize that every facility may not have this set up available, every attempt should be made to closely approximate it.
35 mm Kodak carousel compatible slide projector with screen, remote and a spare bulbPaper flip chart )preferred) or dry board (with markers) or chalk board (with chalk)Upright podium at the front of the room6’ table (18 to 24”) at the front of the room
Sincerely,
Connie B. MinenEducation Coordinator
Room temperature is extremely important. An environment too hot or cold is not conducive to learning. Please make sure the speaker knows the location of the thermostat control.
The following audio-visual equipment will be necessary and should be in the classroom by 7:00 AM on the day of the workshop:
Our staff is looking forward to assisting you with this important educational opportunity. Thank you for choosing Bard Access Systems. If you have any questions, please call our education department at (800) 443-5505, extension 4981.
BASIC WORKSHOP BINDER ORDER FORM
Bard Access Systems Education Department Date:
Shipping Information Method of Shipping__UPS Ground__UPS 3-Day__UPS 2-Day__UPS Overnight Afternoon__UPS Overnight Morning__UPS Overnight 1st Morning__Ship:
(Please call Tina Uhrhan at (801) 595-5406 with questions on this shipment.)
PICC Workshop
PICCMAN3
Bard Access Systems Office Use Only Date:
ProductQuantity Code Number
Notes:
Reference Number: P.O. Number: 0
Vascular Access Device (selection, insertion and management)
Today Tomorrow
ID #: 0Date: January 28, 2004TM: Autumn KilkerFacility: St. John Oakland Hospital
Workshop Reminders
1.
2.
3.
4. Return packets should include:
Attendance RecordsEvaluationsFee Reconciliation FormPayment of Registration Fees
Note:
Send all Packets to: Bard Access Systems
C/O Connie Minen
5425 West Amelia Earhart Drive
Salt Lake City, Utah 84116
Thank You
Connie Minen, Sales Assistant, 1-800-595-5406
Please remember that the proper documentation and the payment for you class needs to be sent to the Salt Lake City home office within one week following each class.
Use the return the Attendance Record. Make sure that the participants have completed the entire record.
Ensure all class participants have handed in the Evaluations. Evaluation forms can be found at the end of the Manual. Packets will be returned to the TM if evaluations are not included.
Certificates must be issued the day of the class. Recipients are responsible for keeping the certificates and Territory Managers should inform class participants that there is a $10.00 processing fee and 6-8 weeks processing time for duplicates.
P.O. form filled out in its entirety if class will be paid through a P.O by the facility
Future classes will not be scheduled for Territory Managers with late or incomplete packets.