Directions. It is recommended that you first print this form. Next, complete the practice information on the form. Indicate the number of hours the dentist devoted to each Exercise. For each Exercise, please also provide a phrase or two that describes the impact on the practice and on patient care.
If you registered for C.E. credit, the dentist must sign the Verfication section at the bottom, then print and mail to the Executive Office of the American College of Dentists, PEAD Program, 839J Quince Orchard Boulevard, Gaithersburg, Maryland 20878-1614. The C.E. credit information will be mailed to the dentist using the practice mailing address.
Dentist's E-mail (as used in PEAD Registration):
Practice Mailing Address:
Staff Members’ Names:
Block A: Ethical Orientation
Indicate the number of hours the dentist devoted to each Exercise in the space before each Exercise. Also, for each Exercise, provide a phrase or two that describes the impact on the practice and on patient care.
_____ A1. Seeing Ethical Issues in Dentistry
_____ A2. Ethical Approaches
_____ A3. Moral Skills Inventory
_____ A4. Practice Values Survey
_____ A5. The Welcome Letter
Block B: Professional and Community Involvement
_____ B1. Community Engagement Profile
_____ B2. The Practice and the Community
_____ B3. What Kind of Practice Would Be Needed Here?
_____ B4. Practice Profile
Block C: Practice Culture
_____ C1. Statement of Practice Philosophy
_____ C2. Office Ethics Code
_____ C3. Creating a Culture of Quality
_____ C4. Office Climate
_____ C5. Power Talk
Block D: Patient Care
_____ D1. Trust and Loyalty (Patient Satisfaction Survey)
_____ D2. Informed Consent
_____ D3. Comprehensive Care
_____ D4. Continuous Care
_____ D5. Competent Care
_____ Total Hours (that the dentist devoted to the Exercises)
I hereby attest and verify that the office and personnel stated above completed the Blocks, Exercises, and Activities of the Practice Ethics Assessment and Development Program on or before the date indicated on this form. The total hours of my personal commitment to the PEAD program equaled or exceeded 10 hours.
Signed (dentist): ______________________________________