CE Provider | American Academy of Dental Hygiene, Inc.

Submission requirements checklist:

All fees are non-refundable:

Date:

Today's Date

Full Name of Provider /Organization:

Address of Provider /Organization:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address of Provider/ Organization (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Contact Person of Provider/ Organization:

First NameLast Name

Telephone Number:

Area CodePhone Number

Email Address:

Please use a personal email address

Provider /Organization is a/an:

FEIN or SS#:

Corporate Number:

CV/BIO (must include education, work experience, membership in professional organizations and positions held, honors received, presentations made, and authored articles.

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Will each course of study be conducted with the same educational standards of scholarship and teaching as that required of a true university discipline, and be supported by those facilities and educational resources necessary, and comply with this requirement?

YesNo

Will each course of study offered clearly state educational objectives that can be realistically accomplished within the framework of that course?

YesNo

Select anticipated teaching method(s) for courses of study for continuing education:

LectureAudiovisualClinicalSimulationInteractive live-time (Computers, telephone or video-conferencing, or other electronic mediums)Non-interactive home study (Computers, tape recorded and correspondence courses)Other (describe)

Will participants completing courses of study for credit be required to provide a written evaluation of the quality of the course?

YesNo

Will all courses offered be a means of an orderly learning experience in the area of dental and medical health, preventive dental services, diagnosis and treatment planning, clinical procedures, basic health sciences, or dental practice administration, or the Dental Practice Act and other laws specifically related to dental practice which is designed to directly enhance the licensee’s knowledge, skill or competence in the provision of service to patients or the community?

YesNo

Will courses of study offered for continuing education credit be available to all dental and dental auxiliary licensees?

YesNo

Will each instructor have education and experience in the subject being taught?

YesNo

Will the provider furnish written certification to each licensee that the licensee has met the attendance requirement of the course?

YesNo

Is provider aware of the record keeping requirements in the event a state board conducts an audit of those courses offered for continuing education credit?

YesNo

Blank course evaluation form:

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Blank certificate of attendance:

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Program brochure/course description, objectives, number of CE credits, date & location of program

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As an American Academy of Dental Hygiene (AADH) approved provider, I fully understand the requirements as outlined by the following documents.

• Standards of Quality Continuing Education

• Guidelines for AADH Approval of Provider and Courses.

I agree to follow these documents for all Continuing Education programs I present. I also understand that failure to do so may result in the termination of my Approved Provider status.

Attestation: Provider/ Representative's Signature:

Upon committee approval, you will be notified via email and sent an invoice for the final payment due. The time period of this agreement is one year (two years for corporations) and valid starting on January 1st through December 31st of the year of application.

Certification: Provider/ Representative's Signature:

Continuing Education Provider Application

Fee Schedule:

Continuing Education Provider Category Definitions:

Courses of Study:

Instructors:

Records:

Standards for Quality Continuing Education:

Attestation:

Certification:

Payment: