Academy Course Approval Packet

(PDHA)

ContinuingEducationCourseApprovalProcedures

To:ContinuingEducationCourseProviders

From:AcademyCourseAccreditationChairperson

Enclosedforyourusearetheguidelinesandforms tosecureapprovalforyourcontinuingeducationcourses.Theseformsmaybeduplicated.Pleasefollowtheguidelineslistedbelowforcreditapproval.Theprocedures areoutlinedonthemainapplicationform.Feelfreeto contacttheCourseAccreditationChairif youhaveanyquestionsorrequireanyindividualassistance. Course Accreditation Chair: Rosetta Mazurkewicz, email: , phone number: 717.626.27.61

Guidelines:

1.Courseshouldbesubmittedatleast45dayspriortothedateofthecourse.

2.Businessmeetings,announcements,lunches,andbreakswillnotbecountedinthenumberofhoursawardedcredit.

3.Coursesshouldbesubmittedforapprovalpriortopublicationofthecoursetoavoidmiscommunication/embarrassment.Notallcoursesareapprovedforcreditorfor

thenumberofhoursrequested.

4.FailuretocomplywiththestatedguidelinesmayresultinfailuretoobtainCEUs.

5.Makecheckpayableto:PDHA.Feescheduleonapplicationform.

All course sponsors must submit:

1.Their course participation lists to the Course Accreditation Chair as soon as possible upon completion of the course. This information must be receivedwithin30daysafterthecoursehasbeen given. The course participant list must be submitted using the Excel sheet format provided. NO OTHER forms, hand-written lists, etc. will be accepted. Please access the form at:

2.AsummaryoftheEducationalProgramEvaluationForms(CourseEvaluation)

Besuretofollowthe guidelinesabovetosecureapprovalaswellastoensurethatallparticipantsareplacedinthePDHAcomputer.Ifaparticipantmisplacestheircertificate,transcriptsofPAAcademy-approvedcourses areavailableforanominalfee.Itistheresponsibilityofeachparticipanttodetermineifaparticularcourseisacceptableforlicenserenewal.TheAcademydoesnotendorseorrecommendanyindividualcontinuingeducationcourseandisnotaccountableforthequalityofanycoursecontent.CertificatesofAttendanceshouldberetainedbylicenseesintheirownpersonalprofessionalfile.

Pleasesendcompletedpacketsto:

AcademyCourseAccreditation

Anita Jackson

621 N. George St

York, PA 17404

ApplicationforPriorApprovalof

ContinuingEducationProgram

Provider: CourseTitle: Presenter: Date: Location: ProgramContactPerson:

Name: Address:

TelephoneNumber:E-Mail:

TypeandLengthof Presentation:

(60Minutes=1CEU,30Minutes=0.5CEU)

LectureHours

Clinical/LaboratoryHours

StartTime:______

End Time:______Break:______

☐New Course(check one)

TotalContactHours

☐Repeat Course

Attachments:Thefollowinginformationmustbeprovidedwiththisform(sendcopiesonly):

1.Curriculumvitaeofpresenter

2.Courseoutlineand/orbriefsummary

3.CourseEvaluationform:threeprovided -chooseone,orsend acopyofyours(Summaryofresponsestobesentwithlistofparticipants)

Note:Allapplicationmaterialsmustbereceiveda minimumof30dayspriortothecourse.

Pleasemailcompletedpacketwiththeregistrationfee.MakecheckpayabletoPDHA.Oneformpercourseeachtimethecourseisgiven.CourseApprovalFeeis$25.00percourse.LATEFEE:If courseapprovalisreceivedlessthan10dayspriortothecourse,thereisan$25.00additionalfee.

SendTo:

AcademyCourseAccreditation

Anita Jackson

621 N. George St

York, PA 17404

Attendance Sign-InForms

ThefollowingpageisanexampleofanAttendanceSign-Inform.Thisformis usedasevidencethattheparticipantswerepresentandisforyouruseonly.Manyprovidersalsowishtogatherinformationabouttheparticipantsforfutureseminars.Thisformcanbeused forcross-checking yourinformationandDOESNOTneedtobereturned.TheListofParticipants/LicenseNumberssatisfiestheinformationrequiredforAcademypurposes.

HelpfulHint:Attheconclusionofthecourse,theparticipantshouldhand inthisformalongwiththeEducationalProgramEvaluationForm.Uponreceiptofthesesheets,theproviderorcoursefacilitatorwillhandtheparticipantaCertificateofAttendance.

PleaseNote:PDHA has new software that allows all PDHA members to view their continuing education credits as well as the ability to save and/or print out their own transcripts. Non-members will still be able to purchase a copy of their transcripts through PDHA’s Central Office.

In order to have transcripts accurate and up-to-date, we are requesting that all course sponsors submit their course participant lists as soon as possible upon the completion of the course. The course participant list MUST be submitted using the Excel sheet that can be accessed by clicking: No other forms, hand-written lists, etc. will be accepted.

In completing the form, please include the participant’s name and full hygiene/ dental license (include the two letter prefix and the six numerals.) Email addresses are optional, however, by submitting their email address it will assure them of receiving all future communications from PDHA on continuing education offerings, event opportunities, etc. Any participant may be removed from the email listing at any time.

Request: please make sure all information is correct. A license number with one incorrect numeral will give course credit to the wrong person!

The Excel spreadsheet should be returnedtotheCourseAccreditationChairalongwithasummaryoftheEducationalProgramEvaluationForms(CourseEvaluation) by email to: .

Your cooperation in implementing this procedure is greatly appreciated. If you have any questions, please do not hesitate to contact the Course Accreditation Chair:
Rosetta Mazurkewicz, RDH, PHDHP

717-626-2761

ATTENDANCESIGNINFORM

ContinuingEducationCredit

PleasecompletethisformandgiveittotheSessionFacilitatorattheconclusionofthiscoursetoreceive yourCertificateofAttendance.

PLEASEPRINTLEGIBLY-Informationwillnotberecordedincomputerifillegible.

Name:

Address:

City:

State:

Zip:

Dentist/HygienistLicense#/CDA#:

(MustbeincludedtoberegisteredinthePDHAcomputer.)

Phone:

Email:

Title:

Presenter:

Provider:

Hours:CEUsDate:

PleaseCheck:

DentistForLicensedHygienistsOnly:

DentalHygienist

DentalAssistant(CDA,EFDA,Orthoetc.)

OfficeManager

ADHA/PDHA Member

PDHAAcademyMember

Receptionist/OtherStaffMembers(SeparateMembershipRequired)

Student/NoDentalHygieneLicense

Student/DentalHygieneLicense

NonMember

PLEASENOTE:

EachparticipantreceivesaCertificateofAttendanceattheendofeachseminarthus receivingcreditforthe course.YourproofofattendanceataseminarisyourCertificateofAttendance.Eachparticipantisresponsibleforkeepingtheirowncertificates.Yournameand

dentist/dentalhygienistlicensenumber/CDAnumberwillbeenteredinthePennsylvaniaDentalHygienists’Associationcomputer.Ifthisinformationisnotincludedonthisform,PDHAhasnomechanismfortrackingyourcredits.ThisinformationisnotsenttotheStateBoardofDentistry. Ifaparticipantmisplacestheircertificate,transcriptsofPA-Academyapprovedcoursesareavailableforanominalfee.PDHACentralOffice717-766-0334.

EducationalProgramEvaluation Forms(Course Evaluation)

ThefollowingpagesareexamplesofEducationalProgramEvaluationFormsthataregiventoeachparticipantbeforethestartoftheprogramandaretobeturnedinattheconclusionofthecourse.Thiswillhelpyoutoevaluateyourprogramsandassistyou inplanningfor futureones.Ifyou choosetouseyour owncourse evaluation,pleasesend acopywithyour application.

If not,pleaseinformthe CourseAccreditationChairwhichcourseevaluation you wishtouseoronewillbechosen.

HelpfulHint:Attheconclusionofthecourse,theparticipantshouldhand inthisformalongwiththeAttendanceSign-Inform.Uponreceiptofthesesheets,theproviderorcoursefacilitatorwillhandtheparticipantaCertificateofAttendance.

PleaseNote:Asummaryofevaluationformsneedstobereturnedtothe CourseAccreditationChair longwiththeExcel Attendee Spreadsheet withtheirdentist/dentalhygienistlicensenumbers/EFDA/CDAnumbers.

Pleasehelpustoimprovethequalityandvalueofourfuturecoursesbycompletingthisform.

Instructor:(Overall)

Excellent Good Fair Poor _NA

Usedeffectiveteachingmethods:ExcellentGoodFairPoor _NA

Speakingstyle:

Excellent Good Fair Poor _NA

Communicatedcourseconcepts:ExcellentGoodFairPoor _NA

Course:(Overall)Syllabus:Handouts:

Audio-visualsmaterials:

Excellent Good Fair Poor _NA

ExcellentGoodFairPoor _NA

Meetingroom:

Excellent Good Fair Poor _NA

Wouldyourecommendthiscoursetoacolleague?YesNoMaybe

AdditionalComments:

Howfarareyouwillingtotraveltoa CECourse?DistanceTime

Whatday (s)andtime(s)arethemostconvenientto attend a CEcourse?

Suggestionsfortopicsforfuturesprograms:

Whatattractedyoutothisprogram?

thesubject

the speaker

dateandlocation

tofulfilllicenserenewal

advertisement(brochure/catalog)

recommendationofcolleague

other,please specify

Checkthesquarethatbestdescribesyour evaluationofthesession,usingotherprogramsyouhaveattendedascomparison,whereapplicable.

1.Formatofpresentation

2.Usefulnessofinformation

3.Effectivenessofpresentation

4.Effectivenessofhandouts/supportmaterials

5.Overallevaluation

GreatGoodFairNeeds

Improvement

Would yourecommendthissessiontoacolleague?YesNoMaybe

Additionalcomments:

Suggestionsfortopicsforfuturesprograms:

EducationalProgramEvaluation

PleasecompletethisformandgiveittotheSessionFacilitatorattheconclusionofthiscoursetoreceive yourCertificateofAttendance.

Provider:
Title:
Presenter:
Course#:PA Hours: CEUs Date: ______

Thefollowinginformationwillbebeneficialinevaluatingthisprogram.Pleaseplaceacheck-markinfrontoftheappropriateresponseto eachofthe followingstatements.Thank youforyourassistanceincompletingthisevaluation.

1.Thecontentoftheprogramwaspertinenttomyneedsandinterests:

extremelypertinent

mostlypertinent

somewhatpertinent

notpertinent

2.Directapplicationofthecontentpresentedwillbeofbenefitinmypatientcare:

extremelypertinent

mostlypertinent

somewhatpertinent

notpertinent

3.Theobjectiveswereclearlypresentedandmet:

extremelypertinent

mostlypertinent

somewhatpertinent

notpertinent

4.Thespeakerwaseffective,wellprepared,andpresentedthematerialinanorganizedmanner:

extremelypertinent

mostlypertinent

somewhatpertinent

notpertinent

5.Iacquirednewknowledgefromthisprogram:

extremelypertinent

mostlypertinent

somewhatpertinent

notpertinent

6.Additionalcommentsandsuggestions:

7.Suggestionsfortopics forfutureprograms:

Certificate of Attendance

Thefollowingpageisan exampleofaCertificateofAttendanceformthatisgiventoeachparticipantaftertheyhavecompletedthecontinuingeducationcourse.Thisformshouldhavetheappropriateinformationplacedonitpriortothecourse.This formactsasproofoftheparticipant’sattendance.

Ifyou choosetouseyourownCertificateofAttendance,the followingstatementistobeincludedon yourcertificateaspartofthePAAcademyofDentalHygieneStudiescourseapproval.

particularcourseisacceptableforlicenserenewal.However,applicantsshouldbeawarethatnotallcoursesofferedandapprovedbytheAcademyareapprovedfor

ContinuingEducationcreditsbytheStateBoardof Dentistry.TheAcademydoesnotendorseorrecommendanyindividualcontinuingeducationcourseandisnotaccountableforthequality ofanycoursecontent.Certificatesof Attendanceshouldberetainedbylicenseesintheirownpersonalprofessionalfile.

PleaseNote:TheAcademyCourseAccreditationChairwillsend yourlist ofparticipants

alongwiththeirdentist/dentalhygienistlicensenumbers/EFDA/CDAnumberstobeplacedinthePDHAcomputer. If aparticipantmisplacesorlosestheircertificate,transcriptsofPA

Academy-approvedcoursesareavailableforanominalfee.

Lancaster LebanonYorkDentalHygienists’Association

Thiscertifiesthat

hastakenthefollowingcourse

“Course Name”

Presentedby:

Example: TinaKeffer, RDH,BS

Example: ColgateOralPharmaceuticals

PA2770R6

2.0CEUsAugust 12, 2006

ThiscoursehasbeenapprovedbythePennsylvaniaAcademyofDentalHygieneStudies.“AcademyApproval”indicatesthatacontinuingeducationcourseappearstomeetselectedcriteria.Itistheresponsibilityofeachparticipanttodetermineifaparticularcourseisacceptableforlicenserenewal.However,applicantsshouldbeawarethatnotallcoursesofferedandapprovedbytheAcademyareapprovedforContinuingEducationcreditsbytheStateBoardofDentistry.TheAcademy doesnotendorseorrecommendanyindividualcontinuingeducationcourseandisnotaccountableforthequalityofanycoursecontent.

CertificatesofAttendanceshouldberetainedbylicenseesintheirownpersonalprofessionalfile.