American Board of Dental Public Health
Annual Continuing Education Record
Address : / Telephone:
City, State Zip : / Reporting Period : / January – December 20 [Add year.]
Continuing Education Credits
Type / Dates / Title / Sponsor / Competency Not Required / Role / #Credits
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
1 = Courses/Lectures2 = Conferences/Professional Meetings3 = Workshops/Symposia/Seminars4 = Publication in a Peer Reviewed Journal5 = Publication in a non-refereed journal6 = Book or Book Chapters7 = Individualized Instruction9 = Others / 1 = Participant2 = Presentor3 = Author4 = Other
Total number of credits requested: / 0.0
Total number of credits approved:
"Click here to Calculate Credits when you are Finished!"
I hereby certify that the Annual Record of Continuing Education Activity represents a true and accurate report for this period. The reporting period is from January to December.
Type Name/Signature: ______Date: ______
[ ] By checking this box, I am providing my electronic signature approving all the information entered on this form. (Please enter name and date on signature and date lines above).
Note: Competency: No longer required.Starting 2012 do not send electronic copies to the Executive Director, ABDPH. If you have any questions, please contact the Executive Director by email ().
ABDPH-Continuing Education-Record.docx; Page 1 of 2; Rev. 02/24/2014
Instructions
The ABDPH began a recertification process in 2000. Recertification information can be downloaded from the American Association of Public Health Dentistry Home Page, or obtained from the Executive Director, ABDPH.
Completion of the form annually is mandatory for those diplomates certified after January 1, 2000 and voluntary for those certified before that date.Diplomates are responsible for maintaining their own records including keeping copies, documentation and summaries of their CEUs forms to document compliance with the Recertification Process. Documentation MUST include the summary of CEUs AND scans of the certificates of CE completion from the organizer of the CE (e.g. NOHC, AADR, etc. Save the CE Record after adding your First Name Initial, Last Name, and CE data year (e.g. CE Record –JAlderman-2013. Ten percent of diplomats who are recertified are audited.
Note: Do not send electronic copies to the Executive Director, ABDPH. If you have any questions, please contact the Executive Director by email ().
Please use the following codes to report all your activities for the reporting period. The reporting period is from January to December.
Type:
1 = courses/lectures
2 = conferences/professional meetings
3 = workshop/symposia/seminars
4 = publication in a peer reviewed journal
5 = publication in a nonrefereed journal or agency reports/manual/background papers
6 = book or book chapters
7 = individualized instruction
8 = others
Guidelines for Continuing Education Credits:
Acceptable continuing education shall mean learning activities which contribute to maintaining or enhancing competency in dental public health. The following types of activities are acceptable for credits:
1.Attendance at and/or delivery of a formal continuing education course. Documentation or letters of completion from the American Association of Public Health Dentistry, International/American Association for Dental Research, American Public Health Association, Association of State and Territorial Dental Directors, and other recognized national and international organizations who have institutionalized continuing professional development programs related to the competency objectives in dental public health are acceptable.
2.Documentation or letters of completion from other sponsors of continuing education relevant to the field of dental public health are acceptable provided the number of hours of activities can be directly linked to the dental public health competency statements (J Public Health Dent 1998; 58 (Suppl):114-18).
3.Authorship of publications related to dental public health will be given credits. A publication is defined as a book, a chapter of a book, or a paper published in a professional journal. Publications of manuals, workshop proceedings, and background papers are also acceptable. The acceptable number of credits will vary from 5 to 10 depending upon the nature of the publication.
4.Attendance at formal lectures, symposia, workshops and conferences relevant to the field of dental public health. This activity will be given credit provided the material presented is organized around and directed toward identified competency statements. The number of credits will be equal to the number of hours attended.
5.Completion of individualized continuing education instruction. Individualized instruction is defined as a course of study which is structured and organized toward accomplishing competency in dental public health. A method of providing feedback to the learner on performance must be incorporated. Documentation of the number of credits must be available for audit.
6.Learning activities that are repeated on a periodic basis will be given credit only once in a ten-year period. The routine performance of teaching duties in an undergraduate or graduate curriculum or the routine participation in organizational meetings will not be given credits.
Dates:Indicate the date(s) of the activity
Title:Indicate the name of the course/lecture/conference/workshop/ symposia/publication
Sponsor:Identify the name of the organization/journal/book
Role:Identify your role as:
1 = participant
2 = presentor
3 = author
4 = other
No. of credits:Indicate the credit hours that appear in the continuing education certificate/letter provided by the sponsoring agency.
Use the following guide for other activities:
Conferences/workshops/symposia - number of hours attended
Publications in a peer reviewed journal, or a book or a book chapter - 10 credits per publication.
Publications in a non-peer reviewed journal or an agency report/manual/ background papers - 5 credits per publication.
ABDPH-Continuing Education-Record.docx; Page 1 of 2; Rev. 02/24/2014