<p> September 2014 Texas & New Mexico Hospice Organization (TNMHO) 1108 Lavaca, Ste. 727, Austin, Texas 78701 ______ACTIVITY BIOGRAPHICAL DATA FORM</p><p>ACTIVITY TITLE: ACTIVITY DATE: Instructions: Use this format to provide documentation of an individual’s expertise as a planning committee member or as presenter/author/content reviewer for this activity. Submitted information must not be more than 2 pages and must be typed. Do not attach any additional material. Check which role(s) you are fulfilling: Nurse Planner Content Reviewer Content Expert Other, describe: Presenter/Author Full Name Degrees Credentials (please spell out) Preferred Contact Address Number and Street City, State and Zip Code Preferred Contact Telephone / - E-mail Address Present Position: Employer Job Title </p><p>Biographical Data Use the space below to briefly describe your professional experience as it relates to your role, as indicated above, in this continuing nursing education activity. Based on the role(s) checked above, complete the appropriate following statement: As Nurse Planner, I have education, experience or knowledge related to ANCC/TNA criteria through (check all that apply): Years of experience with ANCC/TNA criteria Attendance at a recent TNA “Individual Activity Workshop” Date attended: Number of CNE activities the Nurse Planner has successfully completed Graduate education that included ANCC/TNA criteria as a curriculum element Reviewed FAQs & “Approved Provider Activity Guidelines and Criteria” on the TNA Website Mentored by the Approved Provider’s Primary Nurse Planner</p><p>As Content Expert, I have content expertise in this topic by:</p><p>As Presenter/Author, I have content expertise specific to this education activity by:</p><p>As Content Reviewer, I have content expertise specific to this education activity by:</p><p>OTHER: As , my professional experience as it relates to this continuing nursing education activity is:</p><p>Form11092014</p>