Templates for Reporting Substantive Change

REPORTING SUBSTANTIVE CHANGE – HOMETEMPLATESSUBSTANTIVE CHANGE PORTAL  •  NURSE ADMINISTRATOR CHANGE  •  PROGRAM OUTCOMES  •  DISTANCE EDUCATION  •  CURRICULUM  •  PROGRAM TYPES/OPTIONS  •  ENROLLMENT   •  LOCATIONS  •  CHANGE IN STATUS  •  MISSION/GOVERNANCE  •  CONTRACTS/CONSORTIA   •  CLOSINGS/INACTIVATIONS  •  TEACH-OUTS  •  NON-SUBSTANTIVE CHANGES


TEMPLATES FOR REPORTING SUBSTANTIVE CHANGE

Writing a substantive change report? Download a template here!

Templates for reporting substantive changes are listed by substantive change type. The substantive change templates below may not address all substantive changes that the ACEN will review in the interim between a nursing program’s reaccreditation cycles. If you are unsure of which template to use, please contact the Coordinator of Substantive Change at (404) 975-5000.

Please submit completed substantive change reports using the Substantive Change Portal. Substantive Change Reports must be submitted as searchable PDF files. For help creating a searchable PDF, click here.

Select a template from the categories below.

Curriculum
Method of Academic Measurement (.docx)

Changing the way a governing organization or nursing program measures academic progress toward program completion, in clock hours, credit hours, semesters, trimesters, or quarters; or uses time-based or non-time-based methods (ex: clock hours to credit hours)

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Curriculum Revisions (50% or greater) (.docx)

An increase, decrease, or substitution of 50% or greater of the nursing credit/quarter/clock hours that represents a significant departure in the nursing content from the currently accepted/approved nursing courses required for completion of a nursing program (i.e., nursing credits only)

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Credit/Clock Hour Change (20% or greater) (.docx)

Curriculum revisions involving an increase or decrease of 20% or greater of the total credit/quarter/clock hours (nursing and general education/prerequisites credits/hours combined) for the nursing program of study from the currently accredited program of study

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation

Program Outcomes
Licensure/Certification Examination Pass Rate (.docx)

The program’s overall (aggregated for the program as a whole) annual licensure examination/certification pass rates does not meet the benchmark established in Criterion 5.3 (2023 Standards and Criteria)

    • Note: All programs with APRN options are also expected to adhere to the current National Task Force Guidelines for Evaluation of Nurse Practitioner Programs as well as other requirements of the specialty organizations as they apply to the current ACEN Standards and Criteria.

See crosswalk between ACEN Standards and Criteria and 2016 National Task Force Guidelines for Evaluation of Nurse Practitioner Programs

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification


Program Completion Rate (.docx)

The program’s overall (aggregated for the program as a whole) annual program completion rate over two (2) consecutive academic years (e.g., from 2021 to 2022) falls 25% or more below the program’s established expected level of achievement (ELA); or the annual program completion rate in a single year falls more than 40% below the program’s established ELA

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification


Job Placement Rate (.docx)

The program’s overall (aggregated for the program as a whole) annual job placement rate over two (2) consecutive academic years (e.g., from 2021 to 2022) falls 30% or more below the program’s established expected level of achievement (ELA); or the annual job placement rate in a single year falls more than 45% below the program’s established ELA

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification

Distance Education

Distance Education (50% or greater) (.docx)

Offering 50% or greater of the number of nursing credit/quarter/clock hours of the via distance education.

    • Note: Once approved to offer any nursing program via distance education, approval is not required to offer subsequent nursing program(s) via distance education.

See “Distance Education” and “Methods of Delivery” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation

Programs/Program Options
New Program/Degree Type (.docx)

Adding undergraduate or graduate nursing programs of study at a degree or credential level different from that which is included in the nursing education unit’s current accreditation.

See “Nursing Program Type” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: Yes
Focused Visit: No
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


New Program Option (50% or greater) (.docx)

Adding a nursing program option within a nursing program by deleting and/or substituting 50% or more of the existing nursing courses to form the new nursing program option.

See “Nursing Program Option” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Inactivation of a Nursing Program (.docx)

Inactivating a nursing program with intents of reinstatement. See “Inactivation of a Nursing Program” in the ACEN Glossary for more information.

For terminating a program, see Closing a Nursing Program below.

Prior Approval from ACEN Required: No
Focused Visit: No
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Reactivation of a Nursing Program (.docx)

See “Inactivation of a Nursing Program” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: No
Focused Visit: No
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Closing a Nursing Program (.docx)

ALSO REQUIRED:
Teach-Out Agreement (.docx)
OR
Teach-Out Plan (.docx)

See Policy #16 Closings and Policy #36 Teach-Out for more information

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to closure OR immediately after the decision is made when closure occurs within four-month timeframe


Acquiring a Nursing Program (.docx)

Acquiring from another governing organization an accredited or non-accredited nursing program.

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Acquiring an Off-Campus Instructional Site with a Nursing Program (.docx)

Acquiring from another governing organization an off-campus instructional site where an accredited or non-accredited nursing program is offered

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation

Change in Status: Nursing Regulatory Agency/Accrediting Agency/Title IV
State Regulatory Agency Approval (.docx)

A change in approval status with the state regulatory agency for nursing.

See ACEN Policy #17 State Regulatory Agency for Nursing Approval for more information.

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification


Institutional Accreditor Approval (.docx)

A negative or adverse action by the institutional accrediting agency.

See ACEN Policy #18 Accreditation Status of the Governing Organization for more information.

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification


Title IV Status (.docx)

Financial Stability (.docx)

Change in Title IV, Higher Education Act status or financial stability when the ACEN serves as the Title IV gatekeeper.

See Policy #33 Financial Responsibility for more information.

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification

Instructional Sites/Branch Campuses/Relocations

New Branch Campus (Title IV Program) (.docx)

Establishing a branch campus at which an ACEN-accredited nursing program is offered.

    Note: Once approved to offer any nursing program at a branch campus within the nursing education unit (NEU) per ACEN records, approval is not required to offer any subsequent nursing program(s) within the NEU at the branch campus.

See “Branch Campus” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: Yes
Focused Visit: Required
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


New Branch Campus (Non-Title IV Program) (.docx)

Establishing a branch campus at which an ACEN-accredited nursing program is offered.

    • Note: Once approved to offer any nursing program at a branch campus within the nursing education unit (NEU) per ACEN records, approval is not required to offer any subsequent nursing program(s) within the NEU at the branch campus.

See “Branch Campus” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: Yes
Focused Visit: Possible

    Note: All new branch campuses must be reported whether or not a focused visit is required

Timeframe for Submission to the ACEN: Four (4) months prior to implementation


New Off-Campus Instructional Site (50% or greater) (.docx)

Establishing a new off-campus instructional site at which students can obtain 50% or more of the number of nursing credit/quarter/ clock hours required for completion of an ACEN-accredited nursing program.

    Note: Once approved to offer any nursing program at an off-campus instructional site within the nursing education unit (NEU) per ACEN records, approval is not required to offer any subsequent nursing program(s) within the NEU at the off-campus instructional site.

See “Off-Campus Instructional Site” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: Yes
Focused Visit: Required for first two (2) new off-campus instructional sites for Title IV programs

    Note: All new off-campus instructional sites must be reported whether or not a focused visit is required

Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Relocating an Off-Campus Instructional Site (.docx)

Relocating a currently approved off-campus instructional site serving the same geographic region where the nursing program is offered

Prior Approval from ACEN Required: No
Focused Visit: Possible
Timeframe for Submission to the ACEN: Prior to implementation


Relocating an Approved Nursing Education Unit (.docx)

Relocating the primary location for the nursing program

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Inactivation of an Off-Campus Instructional Site (.docx)

Inactivating an off-campus instructional site where a nursing program or nursing program option is offered with intents of reinstatement.

See “Inactivation of an Off-Campus Instructional Site“ in the ACEN Glossary for more information.

For permanently closing a location, see “Closing an Instructional Site” below.

Prior Approval from ACEN Required: No
Focused Visit: No
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Reactivation of an Off-Campus Instructional Site (.docx)

Reactivating an off-campus instructional site where a nursing program or nursing program option is offered.

See “Inactivation of an Off-Campus Instructional Site“ in the ACEN Glossary for more information.

Prior Approval from ACEN Required: No
Focused Visit: No
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Adding a Teach-Out Site (.docx)

Adding a permanent off-campus instructional site at which the governing organization is conducting a teach-out for students of another governing organization that has ceased operating before all students enrolled in an accredited or non-accredited nursing program have completed the nursing program of study

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Closing an Instructional Site (.docx)

ALSO REQUIRED:
Teach-Out Agreement (.docx)
OR
Teach-Out Plan (.docx)

Closing an approved off-campus instructional site or branch campus where a nursing program is offered.

See Policy #16 Closings and Policy #36 Teach-Out for more information

Prior Approval from ACEN Required: No
Focused Visit: No
Timeframe for Submission to the ACEN: Four (4) months prior to implementation

Enrollment

Program Enrollment (50% or greater) (.docx)

An increase in total enrollment of 50% or greater by headcount in one institutional fiscal year for any ACEN-accredited nursing program

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Governing Organization Enrollment (Title IV) (.docx)

An increase in total enrollment of 50% or greater by headcount in one (1) academic year for the governing organization when the ACEN serves as the Title IV gatekeeper

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation

Mission/Governance/Organizational Structure

Ownership/Legal Status/Control (.docx)

Changing the ownership, legal status, or form of control of the governing organization, including merger(s)

Prior Approval from ACEN Required: Yes
Focused Visit: Title IV: Required; Non-Title IV: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Merger/Consolidation (.docx)

Merging/consolidating two or more governing organizations/nursing programs

Prior Approval from ACEN Required: Yes
Focused Visit: Yes
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Mission/Objectives (.docx)

Substantial change in the established mission or objectives of the governing organization or its programs (this does not include a revision/update in the mission statement)

Prior Approval from ACEN Required: Yes
Focused Visit: Title IV: Required; Non-Title IV: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Nurse Administrator Change (.docx)

See “Nurse Administrator” in the ACEN Glossary for more information.

Prior Approval from ACEN Required: No
Focused Visit: No
Timeframe for Submission to the ACEN: No later than one (1) month after permanent or interim nurse administrator assumes duties/responsibilities


Organizational Structure (.docx)

Significant change in the organizational structure of the nursing education unit that would place a nursing program in non-compliance with ACEN Standards and Criteria

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Composite Score (.docx) (Title IV programs)

The governing organization’s most recently published Financial Responsibility Composite Score being 1.0 or less

Note: Only applies to governing organizations that are proprietary or private nonprofit.

Prior Approval from ACEN Required: N/A
Focused Visit: Possible
Timeframe for Submission to the ACEN: Within 60 calendar days of the program receiving notification

Consortia/Contractual Agreements

Contractual/Consortia Relationship (.docx)

Entering into a contractual or consortia relationship with an entity to jointly offer all or part of a nursing program.

Note: This does NOT include entering into an articulation agreement.

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation


Relationship with Non-Title IV Organization (.docx) (Title IV programs)

Entering into a relationship under 34 CFR 668.5 which an entity not certified to participate in Title IV, HEA offers 25% or more of the clock hours or credit hours required for completion of a nursing program

Prior Approval from ACEN Required: Yes
Focused Visit: Possible
Timeframe for Submission to the ACEN: Four (4) months prior to implementation