AMERICAN DENTAL HYGIENISTS' ASSOCIATION

AMERICAN DENTAL HYGIENISTS’ ASSOCIATION
2014 CENTER FOR LIFELONG LEARNING
AT THE 91 st ANNUAL SESSION
2014 CE PROGRAM PROPOSALS
The 2014 CLL at Annual Session will be held in Las Vegas, NV, June 18 - 24, 2014.
INTERESTED SPEAKERS MUST COMPLETE THE 2014 CONTINUING EDUCATION
PROGRAM PROPOSAL IN ITS ENTIRETY AND SUBMIT ELECTRONICALLY NO
LATER THAN WEDNESDAY, MARCH 6, 2013 TO ADHA AT cll@adha.net.
All presenters must be approved in advance. ADHA reserves the right to refuse a
presentation if it is commercial in nature or if the speaker is not educationally and/or or
experientially qualified to present a CE-credited class.
The Goals of the ADHA Center for Lifelong Learning (CLL):
1. To develop an educational program consistent with the mission and goals of ADHA.
2. To provide relevant, unique, and timely content delivered by qualified and
experienced presenters with expertise in their field.
3. To improve the knowledge, skills and ability of dental hygienists in order to provide
quality care and service to the public and profession.
Complete ADHA Continuing Education Guidelines are found on the last page of the CE
Program Submission Form.
Checklist of Required Information:
Course
Title
Description
Objectives
Format
Timeframe
Set-up requirements
Audience
References
Sponsorship
Speaker(s)
Name
Bio
Short vitae
Availability
Membership
Honorarium
Book signing/sales
Photo
Please note: Incomplete proposals will not be considered.

2014 ADHA CLL at the 91 th Annual Session
CE Program Proposal Submission Form
2014 CONTINUING EDUCATION PROGRAM PROPOSAL
Course Title: ________________________________________________
Speaker(s):_______________________________________________________
Speaker Bio(s) (please limit to a paragraph):
Short Speaker Vitae (not to exceed 4 pages for each speaker):
Date Availability: Please select ALL dates you are available to present.
Thursday, June 19, 2014 Friday, June 20, 2014 Saturday, June 21, 2014
Comments:____________________________________________________________
Membership:
Please indicate membership of ADHA:
Not an ADHA member
Yes, ID# ___________(for each speaker)
Travel/Hotel:
The following is provided for all CLL speakers:
• Air Fare to/from event (coach)
• 1 night hotel accommodations
• Ground Transportation (not to exceed $50 each way)
Comments:____________________________________________________________
Honorarium:
In addition to travel and hotel, requested honorarium is $______
Book Signing:
If you are interested in having a table in the back of the course room in order to sell
books/materials, ADHA will adjust your honorarium. Please indicate your intent:
No, I do not want a table for book signing/sales of materials
Yes, I want a table for book/material sales and agree my honorarium will be adjusted.
Photo:
I have included in my submission a high resolution jpeg photo for each speaker.
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2014 ADHA CLL at the 91 th Annual Session
CE Program Proposal Submission Form
Course Description:
Learning Objectives: At the conclusion of this course, participants should be able to:
Course Format:
Please indicate which best describes the presentation format:
Single Interactive Lecturer
Breakout Groups
(Maximum course participants: ____)
Case Study Presentation
Hands-on
(Maximum course participants: ____)
Panel Discussion
Time Frame:
Please indicate which best describes the presentation time frame, including a question and answer
period:
1-2 hours
2-3 hours
3-4 hours
More than 4 hours
Other __________
Preferred/Ideal Audience Size:
Based on course objectives, please indicate the ideal attendance number for this course:
25-50 attendees
50-100 attendees
100-150 attendees
Other_____
Special AV Requirements:
Please indicate any AV requirements requested for this course, in addition to the standard set
which includes a standard sized screen, projector and
microphone:______________________________________________________________
Other Special Requirements:
Please indicate any other special room requirements requested for this course (for example,
internet availability, larger screen 3:1, power, special equipment, limited capacity, additional staff):
_____________________________________________________________________________
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2014 ADHA CLL at the 91 th Annual Session
CE Program Proposal Submission Form
References:
Please provide previous venues where this course has been presented, including a summary of
evaluations and number of attendees:
Venue 1:
Evaluation Summary:
Number of Attendees: ____
Venue 2:
Evaluation Summary:
Number of Attendees: ____
Will this course be presented elsewhere in 2013 or 2014?
No, this course will not be presented elsewhere in 2013 or 2014.
Yes. Please indicate where and when this course will be presented in 2013, 2014:
Has this course been sponsored in the past?
No, this course has not previously been sponsored.
Yes. Please indicate when and by what corporations:
Do you have an established relationship with a corporation/organization?
No
Yes. Please describe:
**PLEASE NOTE – Solicitation of funding is the responsibility of ADHA.
Key Contact Information:
Please provide contact information for the individual designated as the primary contact for this
submission:
First Name: ________________ Last Name:_______________________
Address: ___________________________________________________
___________________________________________________________
Email: ___________________ Phone: ____________________________
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2014 ADHA CLL at the 91 th Annual Session
CE Program Proposal Submission Form
ADHA Continuing Education Guidelines
Course content and speakers will be selected based on the ability to complement other course
offerings. The focus will be to create a balanced educational program, while also meeting the
needs of the professional roles of the dental hygienist. The program content will be relevant to the
educational needs and interests of the intended audience as defined through annual, objective
survey assessments conducted by ADHA, and through defined regional interest and scope of dental
hygiene practice as noted in the state practice act/s.
ADHA is responsible for ensuring that the educational program developed, including goals,
objectives, and content, is based on current dental hygiene practice and in the spirit of the
ADHA-defined Standards for Clinical Dental Hygiene Practice, seeks to address issues highlighted in
the ADHA Research Agenda, promotes the professional roles of the dental hygienist, and does not
conflict with or appear to violate the ADHA Code of Ethics.
Program topic selection will be based on the perceived needs for professional information and
not for the purpose of endorsing specific products or services. ADHA is responsible for requiring
that presenters ensure that all clinical and/or technical continuing education activities offered have
a sound scientific basis, proven efficacy and ensure public safety.
Requirements:
• Written educational objectives defining learning outcomes must be developed for each
continuing education course.
• Professional colleagues invited to present educational sessions must be qualified by
education and experience in order to provide instruction in the defined subject matter.
• The educational methods used must be appropriate to the defined objectives of the program
as well as to the knowledge and skill level of the intended audience.
• ADHA requires that presenters disclose to the association and to participants and/all
commercial relationships of the presenter.
• External funding for any continuing education course will be disclosed to participants in
promotional and educational materials, as well as prior to the presentation itself.
• ADHA requires that presenters disclose to participants any monetary or other special
interest the presenter may have with any company whose products are discussed in their
continuing education program.
• ADHA requires that presenters include a balanced representation of all products and/or
treatment options, or that the promotional nature of the activity is fully disclosed. In an
effort to impartially present information, ADHA requests that generic names be used, when
possible.
• ADHA requires that within the context of the educational program, no products or
commercial services will be marketed or promoted.
• Signed conflict of interest statements will be obtained from all course presenters.
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