Continuing Health Professional Education • 2500 North State Street • Jackson, Mississippi 39216-4505
Telephone: (601) 984-1300 • FAX: (601) 984-1309
APPLICATION FOR APPROVAL
OF A DENTAL CONTINUING EDUCATION ACTIVITY
1. Please contact UMMC Office of Continuing Health Professional Education (CHPE) to schedule a
planning meeting as soon as possible. This meeting must be held to discuss preliminary program
agenda, faculty and budget. All activities should have a committee of experts in the area(s) of the
planned topic(s). Approval for individual healthcare disciplines requires a planner from each
discipline to be a member of the planning committee.
2. Four to six months is preferable to adequately plan a quality CE program. Prior to the meeting
and completion of the application, members of the planning committee should familiarize
themselves with the application packet and attachments required. For more information visit our
website http://www.umc.edu/conted/
3. Proposed activities should promote improvements and/or quality in healthcare and should be
independent of commercial interests.
4. The application should be typed. It and all supplemental documents must be submitted to the
office of Continuing Health Professional Education for review and approval.
5. Invitation letters to commercial supporters and exhibitors should be submitted to UMMC CHPE.
Grants should be signed by UMMC CHPE and other organizations as applicable.
6. A draft copy of all brochures, flyers, postcards, advertisements and other forms of publicity must
be submitted to UMMC CHPE for approval prior to printing. All materials must include the
correct accreditation statements.
7. A short list of post-activity requirements will be sent to the activity designee with the application
approval. This includes a post-activity evaluation.
If you need any assistance or have questions involving the CE application process, contact the office of
Continuing Health Professional Education at 601-984-1300 or 601-815-5141.
Elizabeth G. Franklin, Ph.D., Director, CHPE
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SECTION 1 – ACTIVITY DESCRIPTION
Activity Information
ADA CERP Standard I and VIII
See UMMC School of Dentistry CDE Mission and Goals
Title:
Date(s)
Location (City, State, and Facility) if known
Sponsoring Department:
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SECTION 2—LEADERSHIP
Leadership
ADA CERP Standard IX
See Content Validation Policy
All individuals listed are required to complete a conflict of interest disclosure form related to the content of this activity before
the application will be reviewed and approved.
Directors and activity planners will be kept up-to-date on the requirements for adhering to ADA-CERP criteria via email and
meetings as applicable.
Activity Director
Must be a UMMC faculty member with expertise in the subject of the activity. The director has overall responsibility for
planning, developing, implementing, and evaluating the content and logistics of the activity. The director is responsible for
ensuring that all instructors possess the basic skill, knowledge and experience necessary to assimilate instruction and perform
the treatment techniques taught in the course, as necessary.
Name, title, department, phone, fax, email:
Planning Committee Members
Assists the director with recruiting qualified instructors, the activity design and its implementation.
Names, titles, departments, phone, fax, email:
Administrative Staff Assistant (as applicable)
Assists the activity director and planning committee with necessary paperwork and act as a liaison between CHPE and the department.
Name, title, department, phone, fax and email:
Joint Sponsor(s) (as applicable)
Name and address:
Contact information:
Note: commercial entities are not considered sponsors
Is this joint sponsor accredited by ADA CERP?
Yes
No
Company/Organization Name
Representative Name
Preferred Mailing address
Telephone number
Fax
Email address
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SECTION 3 – PLANNING
Target Audience/Credit
ADA CERP Standard VI, XII, and XIII
Dentists, All
Dentist by Specialty - specify
Dental Hygienist
Dental Assistant
Other Health Care Professionals - specify (example: ENT physicians, surgical registered nurse)
Geographic Location:
UMMC School of Dentistry only
UMMC Center wide
Local (Tri-county area)
Mississippi state wide
Other, specify
Anticipated number of attendees
List any special background requirement(s) necessary to attend this activity.
Will hands on patient treatment be involved, either by course participants or instructors?
Yes
No
If yes, patient protection must be ensured, informed consent from the patient must be obtained in writing prior to
treatment. How will the patients be recruited?
Who will obtain patients and what form will be used?
If yes, all providers, instructors and participants must have liability protection. Proof of liability protection must be
in place prior to the start of the activity.
Number of ADA CERP Hours requested:
Promotional Materials
ADA CERP Standard XI
See Promotional Materials Policy
All promotional materials must be approved by CHPE prior to printing and distributing to potential audience. There are
required elements and statements that must be used in all materials. Failure to get prior approval and statements are incorrect,
will necessitate making the required corrections and redistributing materials or the activity may be denied approval.
What promotional materials will be distributed for this activity? Check all that apply:
Save the date post card
Flyer
Brochure
Journal(s) – specify:
Website – specify (note: CHPE will automatically post on UMMC Continuing Education website)
Other, specify
Identified Professional Gaps and Need of the Learners on which the Activity is Based
ADA CERP Standard II
How were the educational needs of the target audience identified?
● Needs should go beyond the director’s own perceptions of needs/interests and must include input from the dental
advisory committee or its representative.
● There must be documentation of the process used to identify needs/interest.
● Members of the intended audience must be involved in assessing their own educational needs/interests.
Check as applicable and attach documentation. A check mark in the appropriate space below is not adequate documentation.
Method
Evaluation of previous CDE activities
Peer-reviewed journal article(s)
Expert opinion/SOD advisory committee
Request/surveys from target audience
Quality improvement data
Legislative, regulatory or organizational
changes affecting patient care
New technology, methods of diagnosis/treatment
Practice guidelines
Other (specify)
Example of Documentation
Written summary
Abstracts/full article, government document describing
educational need and physician practice gaps
Expert names/medical professional association and summary
of recommendations
Written Summary of requests or survey (phone, mail, email)
Written summary
Copy of measure/change
Description of new procedure, treatment, etc.
Table of contents or executive summary
Label Attachment A
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Learning Objectives
ADA CERP Standard III
See list of Effective Verbs in Formulating Educational Objectives
Written objectives may include, but are not limited to the following categories:
1. Changes in attitude and approach of the learner for the solution of dental problems, corrections of outdated
knowledge.
2. Provision of new knowledge in specific areas
3. Introduction to and/or mastery of specific skills and techniques
4. Alteration in the habits of the learner.
Using action-oriented verbs state what the target audience should be able to do as a result of attending this activity. Do not use
generalities. If more than one topic, a separate learning objective for each is required.
Objectives should read: “Upon completion of this topic, the participant should be able to….”
Complete the activity information form which includes the proposed agenda, dates, times, topics, objectives, content, speakers,
teaching methods and audiovisual.
Complete Attachment B
(Activity Information Form)
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SECTION 4 – DESIGN AND IMPLEMENTATION
Educational Design – Methodology
ADA CERP Standard V and VI
See Content Validation Policy
The activity director/planning committee members are responsible for validating the clinical content so that the activity is
objective, balanced, scientifically valid and independent of commercial influence, either direct or indirect.
All recommendations involving dental medicine in a CDE activity must be based on evidence that is accepted within the
profession of dentistry as adequate justification for their indications and contraindications in the care of patients.
The educational methods must be appropriate to the stated objectives for the activity, the characteristics of the intended
audience, and appropriate to the facilities and instructional medium used for the activity.
Note: If an activity promotes drugs, devices, services or techniques, these are considered promotional and cannot be
designated for CDE credit.
Speakers
ADA CERP Standard VII
See Consultant Fees & Travel Policy
Speakers should be chosen to teach CDE activities should be qualified by education and experience to provide instruction in
the relevant subject matter. The number of speakers should be adequate to ensure effective educational results.
Complete the speaker information form and attach a current curriculum vitae for each non-UMMC guest speaker. Payment of
reasonable consulting fees and reimbursement of out-of-pocket expenses for non-UMMC guest faculty is customary and
proper. All speakers must follow UMMC guidelines for reimbursement. All speakers are required to complete a conflict of
interest disclosure form.
Complete Attachment C
Activity Faculty Information Form
Disclosure of Conflict of Interest
ADA CERP Standard V
See Conflict of Interest Policy
Disclosure forms
Disclosure of financial support or financial relationships between activity directors, planners, speakers and others who have
control over the content for this activity and commercial entities is required. Individuals who fail to return a disclosure form
or refuse to disclosure will be disqualified from participation in the development, management, presentation, or evaluation of
this activity.
CDE courses must promote improvements in oral healthcare and not a specific drug, device, service or technique of a
commercial entity. Activities designed to promote drugs, devices, services or techniques must clearly disclose the promotional
nature of the activity in publicity materials and in the activity itself. Promotional activities cannot be designed for CDE credit.
Disclosure information must be made known to the activity attendees via course syllabus/handouts, publicity material, at the
beginning of the activity via disclosure slide(s), and/or at the beginning of each speaker’s presentation.
Complete Attachment D
(Disclosure Form)
Verification of Disclosure to Attendees – Monitor Critique Forms
Documentation that verifies adequate disclosure occurred must be made via the UMMC disclosure monitor critique form.
These forms must be completed, signed and returned to CHPE immediately following the activity.
Attachment E
(Disclosure Monitor Critique Form)
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SECTION 4 - EVALUATION
Evaluation
ADA CERP Standard IV
Evaluation information is necessary to determine whether or not continuing education activities meet the stated program
objectives, educational methods the University’s overall CE mission. The evaluation process should also assess the quality of
the instructional process, the speakers and the participants’ perception of enhanced professional knowledge.
1.
The effectiveness of this activity will be determined by:
Use of UMC’s standard evaluation form that is completed by the program participant immediately following the meeting
See Attachment F1
(Sample Evaluation Form)
Use of a post-test and/or pre-test
Other process (Please specify.)
2.
If a UMC standardized evaluation form will not be used, please attach a copy of the proposed evaluation form. It must
be approved by the Director or the Associate Director, UMC Division of Continuing Health Professional Education
Label Attachment F2
3.
Following the activity, a synopsis of the evaluation results must be compiled, reviewed and maintained in the UMC
Division of Continuing Health Professional Education Office.
Who will review the results of the program evaluation?
Feedback from this data will be provided to the course director, advisory committee and activity speakers.
4.
5.
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SECTION 5 –FISCAL RESPONSIBILITY
Budget
Standard X
See Commercial Funds Policy
See Consultant Fees & Travel Policy
UMMC adheres to all applicable national and state government regulations for fiscal responsibility.
All activities are cost accounted on an individual basis. Projected income and expenses are determined through discussion with
the activity director/planning committee and the CHPE program administrator assigned to the activity. The PA will keep the
activity director apprised of all income and expenses throughout the planning and implementation of the activity. Upon
completion of the activity, a final budget analysis will be communicated to the director. If the activity incurs a surplus this may
be used for future activities. If the activity incurs a deficit the sponsoring department/division, or if applicable, the joint
sponsor shall be responsible for reimbursing CHPE.
If the activity has a deficit, what will be the mechanism of reimbursement used (example: UMMC account number):
Financial Resources
Standard X
UMMC adheres to all State financial regulations, and ADA Commercial Support.
CHPE will assist with letters of invitation and/or on-line financial application.
Commercial Support
Terms, conditions, and purposes of commercial support must be documented in a written agreement between the commercial
entity and provider, and if applicable, the joint sponsor. UMMC Letter of Agreement (LOA) may be used or the commercial
support may provide their own. All monies supporting UMMC continuing education activities should be made payable to
UMMC-Continuing Health Professional Education.
See Attached UMMC SOD LOA
Exhibit Space
Commercial exhibitors are promotional activities and not continuing education. Monies paid by a commercial interest for these
promotional activities are not considered “commercial support” and therefore a commitment form will suffice for their
participation – no LOA needed. CHPE commitment form may be used for this purpose
See Attached UMMC Commitment Form
DO YOU ANTICIPATE FINANCIAL ASSISTANCE FROM COMMERCIAL ENTITIES?
YES
NO
If yes, have you contacted these sources:
YES
NO
If yes, attach copies of correspondence or other documentation
WILL VENDOR/EXHIBIT TABLES BE ALLOWED AT THIS ACTIVITY?
YES
NO
If yes, have you contacted these sources:
YES
NO
If yes, attach copies of correspondence or other documentation.
Label Attachment G
DO YOU REQUIRE ASSISTANCE FROM CHPE REGARDING EDUCATIONAL GRANTS/VENDOR SUPPORT?
YES
NO
If yes, please discuss with your assigned CHPE program administrator.
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SECTION 6 -BUDGET – RECORD KEEPING
Record Keeping
ADA Standard XIV
UMMC CHPE will maintain accurate records of individual participants for a period of at least six years. Attendees are
responsible for maintaining his/her own records and reporting his/ her CDE activities to all appropriate bodies in accordance
with any jurisdictional and/or membership requirements. Verification of participation will be mailed to attendees by UMMC
CHPE. No other entity may issue verification of attendance for UMMC CDE activities.
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SECTION 7—SIGNATURES
By signature below the signees agree to abide by all standards, policies and procedures indicated in this document and
its attachments.
ACTIVITY DIRECTOR
________________________________________
Typed Name
___________________________________
___________________
Signature
Date
JOINT SPONSOR DIRECTOR (if applicable)
________________________________________
Typed Name
___________________________________
___________________
Signature
Date
For CE Office Use Only:
Number of credits approved:
Approved by:
___________________________________________________________________________ Date:__________________
Pia Chatterjee Kirk, DDS
Director of Dental Continuing Education
___________________________________________________________________________ Date:__________________
Elizabeth G. Franklin, PhD
Director, Continuing Health Professional Education
Rev 5/13; 6/13; 8/13
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