ACADEMYOFDENTAL HYGIENE STUDIES

Pennsylvania Dental Hygienists’ Association

ContinuingEducationCourseApproval

Procedures Independent StudyGuidelines

On occasion, anindividual mayfindthat theyhaveparticipatedin acontinuingeducationprogram that does not havea PA Academy of Dental HygieneStudies CEUnumber. Inthis case, the individual mayapplyfor independent studycredit. Enclosedfor yourusearethe guidelines listed belowtoreceivecredit andappropriatemethodtofollow. Please feel free tocontact the Independent Study Chairif you haveanyquestions orrequire anyindividual assistance. Independent Study Chair is Deborah Gschrey, RDH, BS and phone number is 610.248.8961.

Guidelines:

  1. Fill out the Independent StudyApplication Form.
  2. Attach a copyofthebrochure, advertisement orJournal Article with the course description.
  3. Submit documentationof yourCertificateofAttendancefortheseminar orVerificationof CompletionfortheJournal Article.
  4. Keynoteaddresses, business meetings, announcements, lunches, andbreaks will not be countedinthenumberof hours awardedcredit.
  5. Tohave yourCEUs placedin PDHA’s computerrecords, your dental hygienelicensenumbermust belistedontheapplication.
  6. Sendcopies only, attachments will notbereturned.
  7. Ifotherdental hygienists areattendingthesamecourse, eachparticipant must submit theirown form andregistrationfee.
  8. The registration fee per person per course is:
  9. $3.00 for PDHA Distinguished Academy member.
  10. $5.00 for PDHA Academy member
  11. $8.00 for PDHA/ADHA member.
  12. $30.00 for non- ADHA/PDHA member
  13. PA Academy Independent Study course will be interpreted as appropriate interpretation requirements by the state board of dentistry. If any course is in question, please refer inquires to the state board of dentistry.

Makecheckpayableto PDHA and please mail check ONLY to:

Anita Jackson, 621 N. George St, York, PA 17404

Amount Paid for this course: ______

Pleasesendcompletedpacketto: Thank you for your continued support of our

AcademyCourseAccreditation Academy of Dental Hygiene Studies

PA Academy of D.H. Studies

Deborah Gschrey, RDH, BS

5085 Wagner Dr

Bethlemhem, PA 18020

ACADEMYOFDENTAL HYGIENE STUDIES

Pennsylvania Dental Hygienists’ Association

Independent StudyApplication

Name: ______

Address: ______

______

TelephoneNumber: ______E-Mail: ______

Dental HygieneLicenseNumber: ______

Provider: ______

Title: ______

Presenter: ______

Date: ______Location: ______

Typeof Presentation: (60Minutes =1CEU)

_____ LectureHours

_____ Clinical/LaboratoryHours

_____ Total ContactHours

Attachments:Thefollowinginformationmust beprovidedwiththis form (send copies only):

  1. Attach a copy of thebrochure,advertisementorJournal Article course description.
  2. Submit documentationof yourCertificateofAttendanceor Verificationof

CompletionfortheJournal Article.

The registration fee per person per course is:

  • $3.00 for PDHA Distinguished Academy member.
  • $5.00 for PDHA Academy member
  • $8.00 for PDHA/ADHA member.
  • $30.00 for non- ADHA/PDHA member

Make check payable to PDHA and please mail check ONLY to:

Anita Jackson, 621 N. George St, York, PA 17404

Please send completed packet to: Thank you for your continued support of our

Academy Course Accreditation Academy of Dental Hygiene Studies

PA Academy of D.H. Studies

Deborah Gschrey, RDH, BS

5085 Wagner Dr

Bethlemhem, PA 18020