CONTINUING EDUCATION CERTIFICATE
CSDA CONTINUING EDUCATION VERIFICATION FORM
Virtual Online Conference May 3, 4, 6 and 8 2021
This certifies that I participated in the following continuing education activity via webinar:
Participant Name:_________________________________________________________
Speaker Name: ___________________________________________________________
Title: ___________________________________________________________________
Date of Course: ________________
Time of Course: ________________ Number of Credits: _______ Verification Code:__________
The CSDA is proud to be a recognized ADA CERP Provider.
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The Connecticut State Dental Association is proud to be a recognized ADA CERP Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. The CSDA’s Continuing Education Programs are also accepted by the Academy of General Dentistry (AGD) for Fellowship and Mastership credit. The current term for both is 11/1/19 through 12/31/23. If you are an AGD member, you can mail a copy of this form to the AGD for credit. If you had your badge scanned, the CSDA does submit credits to the AGD on behalf of our members on a monthly basis assuming we have your AGD number on file. CSDA’s AGD ID# is 219236.
Concerns or complaints about any CSDA CE Program may be directed to the CSDA Central Office ext. 203 or to ADA CERP at 1-800-621-8099 ext. 2869. The CSDA CE Council asks that concerns or complaints only be directed to the ADA if you feel you have not received sufficient response from the CSDA.
Please note: You must retain this certificate for your records. DO NOT mail to the CSDA or to the State of Connecticut. The State of Connecticut recommends retaining your CE records for a minimum of three years from the date of completion. Upon request by the Department of Public Health, the licensee shall submit certificates to the Department within 45 days. A licensee, who fails to comply with the continuing education requirements, including failure to maintain proof of course completion, is subject to disciplinary action.
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