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					                                                 DHA CONTINUING EDUCATION LOG
Certification #: _______________________________                                       Certification Period: _______________________________
DHA Name: _________________________________                                            Employer & Village: _______________________________
    1.   You may use this form to record your continuing education.
    2.   Record CE activities for 2 years prior to initial/renewal certification.
    3.   If your agency has a form that collects this information in another format, you may submit that form instead. Please do not send CE certificates unless requested.
    4.   If you have questions, please refer to Chapter 3. Continuing Education (CHAPCB 3.10.050 and 3.10.200), Community Health Aide Program Certification
         Board – Standards and Procedures, as amended. You may also contact the CHAPCB at 729-3624.

                   CHAPCB APPROVED CE                                                                          Supervised Patient Contact
Date             Hours       Topic and Sponsor                                              Date             Hours           Supervising Dentist

Total                                                                                       TOTAL
CE                                                                                          Dental

Required: 24 hours or more in 2 years.                                                                      TOTAL HOURS:
(CE can be 24 hours of CHAPCB Approved CE, or
 24 hours Supervised Patient Contact, or a 24-hour combination of these.)

Form 00-03D (Revised 9/24/08)