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Continuing Education · Pro

Dental Hygienist CE & License Renewal Tracking Form

Easily log continuing education courses, verify mandatory topics, and track license renewal compliance for dental hygienists in one streamlined form.

Use This Template Free Preview

Matcha theme

formbuilder.ai/f/dental-hygienist-continuing-education-hours-certification-renewal-tracking-form

Dental Hygienist Continuing Education Hours & Certification Renewal Tracking Form

Full Name

· · ·

Email Address

· · ·

Phone Number

· · ·

Submit

The Dental Hygienist Continuing Education Hours & Certification Renewal Tracking Form is designed to help licensed dental hygienists and dental practice administrators organize and document all CE activities required for license renewal. It captures personal and licensing details, including license number, issue date, expiration date, and state of licensure, ensuring every submission is tied to the correct professional record.

The form features a repeatable CE course log so hygienists can enter multiple courses completed during a renewal cycle, along with an hours summary section that calculates total submitted hours against state requirements. Built-in compliance checks confirm completion of mandatory topics such as Infection Control, CPR/BLS certification, Ethics/Jurisprudence, and state-specific mandated courses like opioid prescribing awareness or human trafficking training.

Whether you're a solo practitioner tracking your own renewal or a dental office manager overseeing a team of hygienists, this template eliminates manual spreadsheets and reduces compliance risk. Customize it to match your state board's specific requirements and share it digitally for fast, paperless record-keeping every renewal cycle.

4 Pages

20 Questions

~7min To complete

Free No credit card needed

Field types Yes / No ×4 Date ×3 Dropdown ×2 Full Name Email Phone Short Text Repeatable Section number Calculation Long Text singlecheckbox termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Personal & Licensing Information 8 questions

Personal & Licensing Information

1 Full Name * Full Name

2 Email Address * Email

3 Phone Number * Phone

4 State Dental Hygiene License Number * Short Text

5 Original License Issue Date * Date

6 Current License Expiration Date * Date

7 State of Licensure * Dropdown

8 Renewal Cycle Period * Dropdown

Page 2 Continuing Education Course Details 1 question

Continuing Education Course Log

Enter details for each CE course completed during this renewal cycle. Use the repeatable section below to add multiple courses.

1 Course Entry Repeatable Section

Page 3 Hours Summary & Compliance Verification 7 questions

Hours Summary & Compliance Check

1 Total CE Hours Required for Renewal * number

2 Total CE Hours Submitted * Calculation

3 Have you completed the required Infection Control course? * Yes / No

4 Have you completed a current CPR / BLS certification? * Yes / No

5 Have you completed the required Ethics / Jurisprudence course? * Yes / No

6 Have you completed any state-mandated topic-specific courses (e.g., opioid prescribing, human trafficking awareness)? * Yes / No

7 Additional Notes or Explanations (e.g., exemptions, extensions, carryover hours) Long Text

Page 4 Attestation & Submission 4 questions

Attestation & Submission

By signing below, I attest that all continuing education information provided is accurate and complete. I understand that falsification of CE records may result in disciplinary action, including license suspension or revocation.

1 I confirm that all courses listed were completed by an approved continuing education provider recognized by my state dental board. * singlecheckbox

2 I have read and agree to the attestation statement above and understand my obligation to maintain accurate CE records for audit purposes. * termsandconditions

3 Signature * Signature

4 Date of Submission * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.