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Preceptorship program of the American Association of Orthodontists
Preceptorship program of the American Association of Orthodontists Outline of procedure and minimum requiremenb for all constituent societies PROCEDITRE
A. The preceptor must be an active member of the American Association OI Orthodontists, which membership must have been continuous for the previous eight years, and he must have been approved by the Qualifying Committee tc, act as a preceptor. B. The preceptor must be an active member of the constituent society within whose geographical area he maintains a full-time practice. Should the preccpt,or have offices within the jurisdiction of more than one constituent society, 1)~ mutual consent of these societies he may make a choice. C. Both the preceptor and the preceptec shall make formal application to the Qualifying Committee for permission to engage in this program. 1). Upon receipt of this application, a standard questionnaire shall be sent both the preceptor and the preceptee. The questions listed in the two forms art; such as to give the Committee the basic information that it will require in determining the fitness of each applicant to act in his respective capacities. Thcsc* questionnaires are not final, nor do they preclude the Committee from usino other methods of seeking information. E. Upon acceptance, both the preceptor and the preceptee shall be notifictl in writing of the official date of the inception of the preceptorship. %. Should the Qualifying Committee of t,he constituent society refuse either applicant, said applicant shall have the right of appeal, in the following ardor, t,o (1) the Board of Directors, or other governing body of the constituent society. (2) the Qualifying Committee of the American Association of Orthodontists. (3) the Board of Directors of the American Association of Orthodontist,s. whosc~ decision shall be final. B. The preceptor will be permitted to have only one preceptee in training at any given time.
216
American
Association
of
Orthodontists
H. The preceptor shall file with the Qualifying Committee a detailed outline of the course of instruction that he proposes to give the preceptee. This outline must be approved by the Qualifying Committee of the constituent society. I. The preceptee shall spend full time in the exclusive practice of orthodontics under the personal supervision of his preceptor (by “personal supervision” is meant that the preceptor shall be present in the same office at all times that the preceptee is engaged in clinical practice) except during sickness of the latter or while he is on vacation. Should such sickness or vacation be for a period longer than two continuous weeks, the Qualifying Committee shall be so notified. At no time shall the preceptee engage in any other type of practice; nor shall he practice orthodontics outside the office of his preceptor. J. The clinical and laboratory work of the preceptce shall bc open to inspection by the Committee at all times. K. Should either the preceptor or the preceptee become dissatisfied with their association, either or both shall have the privilege of presenting his case to the Qualifying Committee. L. The Qualifying Committee shall in no case insist upon instruction in any certain type of appliance or method of treatment but shall put emphasis upon general orthodontic knowledge. M. The preceptee, upon successful completion of eighteen months of training, shall be eligible for associate membership in the constituent society under whose jurisdiction he is being trained. N. Upon successful completion of the preceptorship program. both the preceptor and the preceptee shall be so notified in writing. MINIMUM
REQUIREMENTS
The course of instruction as submitted by the precept,or and approved by the Qualifying Committee shall serve as the basic guide for the instruction of the preceptee. The preceptee shall be examined by the Qualifying Committee at the end of each pear of his preceptorship. The results of these examinations are to be sent both the preceptor and the preceptee with any recommendations deemed essential to the welfare of the program. The requirements listed herein are minimum requirements, and no revision of this program shall be allowed which is less than those incorporated herein. First-year
examination
to include :
1. Submission of a Typodont with appliance of choice, including auxiliaries, for the treatment of malocclusions for which the appliance is most suitable. 2. Submission of five cases started by the preceptee showing progress to date. 3. A written review of the literature in a subject of the preceptee’s choice. 4. Oral or written examination, or both, to show a knowledge of the basic fundamentals of orthodontics.
Preceptorship
program
2 17
5. General idea and title of proposed thesis, which must be acceptable to the Qualifying Committee. Second-year examination to include : 1. Submission of Typodont with a second appliance of choice, the prcceptee to demonstrate a sound working knowledge of this appliance. 2. Resubmission of original five cases shown, with complete records showing progress to date. Submission of five additional cases under treatment by the preceptee, with complete records to date. 3. Oral or written examination, or both, to show advanced knowledge of clinical orthodontics and basic sciences, of the latter to the extent given in current textbooks. 4. A written review of the literature on a subject of the preceptcc’s choice. 5. Ontlinc of thesis. (Note: Definite progress should be evident at this time. It is the critical stage in the preceptee’s development. j Third-pear examination to include : 1. Comprehensive examination by the Qualifying Committee sitting as an examining board plus written examination to be based on anything pertaining to orthodontics with special reference to the literature of the last fifteen years. (Suggested: Dr. Philip Adams, etc.) 2. Thesis. This should be submitted sufficiently in advance to a.llow for reading by each member of the Committee. 3. Resubmission of ten cases previously shown, with complete records to clatcb,together with five additional cases treated by the prcccptce, with complete records to date. (No~P: Records of all cases submitted should include complete case analy.. sis, outline of treatment, and retention. All cases shown by t.hc prrceptcc should be named and numbered when first, presented. A record of these cases should be kept by the C0mmittee.j
I hereby make application to _---- -___ -_----------------_-____ ----__ Qualifying Committee for preceptorship tra.ining in accordance with its rules and regulations. I enclose $---------herewith. In making this application I agree that the ---_---_-__--_---__-__ - _------ -_~----~~ Qualifying (Yommittee may investigate my qualifications in whatever manner it sees fit, and may refuse to accept my application, or having accepted my application ma;\ have the right to suspend or discontinue my training program at any time. Its decisions shall be final and binding upon me and I shall not and will not question any such action in any court of law or other tribunal nor hold the said -----_---------_____-----Qualifying Committee liable in any manner, legal or otherwise, for any damages which may result from any of the above a&ions. ----------------------, precrptec Signed Date
218
AmericavL Association QUESTIONNAIRE
FOR
of Orthodontists
PRECEPTEES
In requesting permission from the _-____-_----___--_________ Society of Orthodontists to become a preceptee to one of our members, you have signified your intention of preparing yourself for membership in this organization. As an aid in determining your qualifications for the study of orthodontics will you please complete this questionnaire. Please feel free to supply any additional information you may have that is not provided for in the questionnaire.
1. Name in full -_---_---~~~~--~_-~--~~-~~----~~~-~~-~~--2. Address --___--___----_____ -_---_-3. Place and date of birth -- __-_ - -_______ --__ 4. Dental college attended _____ -- _-____-__ - __.. _-__ 5. Date of graduation -_-_-___- ____ ---_----__---6. Did you graduate
in the upper,
7. Other colleges attended
middle,
or lower one-third
of your class?
and degrees received --------_----_----_--------
8. Of what dental societies are you now or have you been a member (give dates of membership) -__-__------_-_---__---------9. Have you ever been engaged in the practice of dentistry _-- _---_ _----_--10. If so, give place and dates --------_-----_----_-------_----__----__--____-----------------------------------------------~---11. In what states are you licensed to practice ~~---__-~--_~-~_-~~_-~---~--~ 12. What are your reasons for wishing to study orthodontics ____-_ -- ____ -___ __~_~~--____--_-_----~----~~~~~-~~-~-----~~~-------~~----~----~-~-~~--~ 13. What is the name of the orthodontist with whom you are contemplating association _-___----__--_---__-____________________ 14. What financial arrangements have you made with the preceptor of your choice _-_-_--___-____-____-----------------------------------------.
15. Have you applied to any recognized dental school for graduate orthodontics __-_--_--_---~--~_-_____________________------~-~----~-~ 16. If so, what was the reply _----- -___ -----_-------_--------------------. ___________~___________________________-------------------------------_---_-----_----__---______________ Signature Date
work
in
QUESTIONNAlRE
FOR PRECEPTORS
By requesting permission from the _-_---_-_----__-____---_Society of Orthodontists for permission to act as a preceptor, you are assuming an Ohli@tion to give a course of instruction that will prepare a st,udent to become a competent orthodontist and one who will be able to qualify for membership in the American Association of Orthodontists. To assist the Admissions Cornmittee in determining your qualifications for this responsibility will you please complete this questionnaire in full. Please feel free to supply any additional iuformation you may have that is not provided for in this questionnaire. 1. Name in full ________________________ --___- ____ -_---___- -__-.-._- -----2. Business address _________________________ - ____ -__-_- _-__----_ ------3. Place and date of birth _____________ -_-__-- ____- --- __--_- ------------4. Dental college attended and date of graduat,ion ____- - _----_ ----..-----___-__-----5. Ot,her colleges attended and degrees reccivrd ______- ------- _-_-_ -_- .._._ ..-c-----__~~_~--___~-____________________~~~~~~~~~~~~~~~--~-~~--~~~~~~-_-------_--_______-_____________________------------------------------6. 7. 8. 9. IO. 11. I?. 13. 14. I5.
Have If so, Dates What Have If so, Dates Hours Have Name
you had graduate training in orthodontics ___---_-----_---_-----~at which school or university ______________ - ___-_ ---_- __-__-.-_- _you were in attendance ___- _________________ --_-- -_-_-_-.- ----_degree was earned, if any _-- ________ -__-_---_-_____---_-----you had postgraduate training in orthodontics __-_--- _-_____- - - - .-at which school or university ______________ ----_- --_-- --_-- .-.. -you were in attendance ___________________ - ____ -__------______.. per week in attendance __________________ -___-- ____ ---_-- -.___- you taken any refresher courses ___________ - ____ ___----_-__-- -_of courses and places given ___________________ -_--_-----_-_ ~--
16. By whom given and the dates _- __________________ 17. What other training
in orthodontics
--_---_----
have you had (give full details)
18. How many years were you in general prac%ice _--_-------__-----_-__ -19. Places and dates _____ ---_----__---_-_-_________________ 20. How many years have you been in the exclusive practice
___-__-_-_ ..--
-..-
____-__- ---_of orthodontics _.
21. Place of practice and dates ___---_-_-_-__----_-------------------.--22. Are you alone in practice or do you share an association ---__~---c~_-_-~ 23. If the latter, give full details -_--___-___-_-_---_---------_____ --- __..
220
American
Association
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Orthodontists
Am.
J. Orthodontics
March1963
24. Are you a diplomate of the American Board of Orthodontics ____________ 25. Of what orthodontic societies are you now or have you been a member _-__ -----_-----_-----__---------------------------------------------------26. Give dates of membership __________ -___- ____ -__-_-__-- ______ -- ______ 27. Are you a member or have you been a member of any study clubs _- _-____ 28. Give name or organization and dates of membership -_-- _________-______ 29. Are you now or have you been a member of any scientific societies other than those directly connected with orthodontics __________------________ 30. Give name and dates of membership --_- ________ --_-- ____--_________31. Official positions held in dental, orthodontic, or other scientific societies -----------------_---__--------------------------------------------------32. Are you now or have you been interested in the field of research __-____-------_-------_--_-----------------------------------------------------33. What is or has been the area of special interest __--__-- _______________~_------------_--_______________________~~-~-~--~~~~~~~~~--~-~~-~~-~--~. 34. List of reports and where published -------__---_-_-_-c_-______-----_---__-___-_-_-_--__--_____________________--------------------------35. Have you read papers before scientific societies __------________-__- --36. Give names of societies, titles of papers, and dates published ____________ ~~_-__-_---__---_-______________________--~~---~-----~-~--~~~~--~~~~---. 37. Have you given clinics or other demonstrations before scientific societies _-__ __------_-------___-____________________~~-~--~~~~~~~-~~~~~~~~~-~-~~--~ 38. Give names of societies, titles of presentations, and date presented _______-
39. Have you taught in a dental or other school ---_--____ -- _________--_--40. Name of school or schools -_- ____________________________ -__-__-- ____ 41. Rank upon leaving _-__--_____------~-_-~-~~-~~-~---~~---~~----~~--42. Subjects taught __--_--_-- _______ -__-_- ____ ---_-_- ____ -__--_-___-_---. ----------------------------------------------------------------------43. Range of years -_______------_-__-_~--~~~~~--~.-~~-~-~----~~~-~-~~~~~. 44. Time devoted to teaching ----__-__----_--___-_________________ ____ --_ 45. Dates of employment --__---_-_---__---_-________ _____ ---__--- ____ --46. Have you ever given any courses of instruction outside of a dental school __ -----_--------_--___--------------------------------------------------47. If so, describe fully ---_--___-__-_______ - _____ ------_-___-_________ ---------_-----_----____________________--~~~~~~~-----~-~--~~~~~~~~~-~~ 48. Dates when such courses were given, place given, under whose auspices _-__ --____-_---_--_--_______________________~~--~~~~~~---~~-~--~~~~~~~~~~~~ 49. Qualifications for those in attendance -----__----__-____--_-__ -__----__ ______-----_-__--___---------------------------------------------------
Preceptorship
Volume 49 Wum her 3
program
22 1
50. Have you ever had an associate in your office _____-____-.---_---------51. If so, please give names and dates of association ------__--____---_ -..--.. _---~-___--_____________________________~~-~~~~~~~~~-~~~~~~--~-~---~~-5%. Do you practice in more than one location _-_------__-_-_ - _--- --..---53. If the answer is “yes,” give addresses of additional locations and time spent in each ________________________________________------_-_-__--_ 54. Do you employ a dental hygienist _____ - _____ -- ____ -_-__---____--_ _55. How many dental assistants, laboratory technicians, secretaries, or othc)r auxiliary help do you employ _--_--__-_-__-____ ----_- ________ -__.-_ _. 56. Do you have your own x-ray equipment - _____ ------_---_-_--___-_. _,557.Do you require cephalometric head films of your patients ___-- --_-_..-_. ._58. If so, for what purpose are they used _-_-___--------_-___ ---__- ___....59. Give in detail your proposed program
of study (by years) for the prereptee
60. Describe your type of treatment, diagnosis, and your general approach to orthodontic procedures as practiced in your office ---_--_ - __-___--I___
61. What is the average number of new cases pou have started in the last five ~-ears__---_---____-____--____________________------------------62. What is your reason for requesting permission 1.0 assume the responsibilit> of training a preceptee -__--_--__--__-----_--__-- __--__---------...63. What financial
arrangement
do you propose to arrange with him -_ -__..-_
_----~-__-------___--~~-----~~-~~~-~~~---~~--~----~--~-~~----~~~--~---~ 64. Will you be responsible for the completion of the treatment of any cases hc undrrtakes while associated with you --~~_~~~------~-------~~ -_-. ___--_--_~~-~~--___~~---~~~---~~-~~~~~-~~~~----~--~~-~-~~-~~-~~~-~~~~~65. What, is the name of the preceptee you are proposing to teach ---_-_ _- --.
~~_-__~_----~~~-----____________ Signature Date
A. The preceptor must be an active member of the American Association OI Orthodontists, which membership must have been continuous for the previous eight years, and he must have been approved by the Qualifying Committee tc, act as a preceptor. B. The preceptor must be an active member of the constituent society within whose geographical area he maintains a full-time practice. Should the preccpt,or have offices within the jurisdiction of more than one constituent society, 1)~ mutual consent of these societies he may make a choice. C. Both the preceptor and the preceptec shall make formal application to the Qualifying Committee for permission to engage in this program. 1). Upon receipt of this application, a standard questionnaire shall be sent both the preceptor and the preceptee. The questions listed in the two forms art; such as to give the Committee the basic information that it will require in determining the fitness of each applicant to act in his respective capacities. Thcsc* questionnaires are not final, nor do they preclude the Committee from usino other methods of seeking information. E. Upon acceptance, both the preceptor and the preceptee shall be notifictl in writing of the official date of the inception of the preceptorship. %. Should the Qualifying Committee of t,he constituent society refuse either applicant, said applicant shall have the right of appeal, in the following ardor, t,o (1) the Board of Directors, or other governing body of the constituent society. (2) the Qualifying Committee of the American Association of Orthodontists. (3) the Board of Directors of the American Association of Orthodontist,s. whosc~ decision shall be final. B. The preceptor will be permitted to have only one preceptee in training at any given time.
216
American
Association
of
Orthodontists
H. The preceptor shall file with the Qualifying Committee a detailed outline of the course of instruction that he proposes to give the preceptee. This outline must be approved by the Qualifying Committee of the constituent society. I. The preceptee shall spend full time in the exclusive practice of orthodontics under the personal supervision of his preceptor (by “personal supervision” is meant that the preceptor shall be present in the same office at all times that the preceptee is engaged in clinical practice) except during sickness of the latter or while he is on vacation. Should such sickness or vacation be for a period longer than two continuous weeks, the Qualifying Committee shall be so notified. At no time shall the preceptee engage in any other type of practice; nor shall he practice orthodontics outside the office of his preceptor. J. The clinical and laboratory work of the preceptce shall bc open to inspection by the Committee at all times. K. Should either the preceptor or the preceptee become dissatisfied with their association, either or both shall have the privilege of presenting his case to the Qualifying Committee. L. The Qualifying Committee shall in no case insist upon instruction in any certain type of appliance or method of treatment but shall put emphasis upon general orthodontic knowledge. M. The preceptee, upon successful completion of eighteen months of training, shall be eligible for associate membership in the constituent society under whose jurisdiction he is being trained. N. Upon successful completion of the preceptorship program. both the preceptor and the preceptee shall be so notified in writing. MINIMUM
REQUIREMENTS
The course of instruction as submitted by the precept,or and approved by the Qualifying Committee shall serve as the basic guide for the instruction of the preceptee. The preceptee shall be examined by the Qualifying Committee at the end of each pear of his preceptorship. The results of these examinations are to be sent both the preceptor and the preceptee with any recommendations deemed essential to the welfare of the program. The requirements listed herein are minimum requirements, and no revision of this program shall be allowed which is less than those incorporated herein. First-year
examination
to include :
1. Submission of a Typodont with appliance of choice, including auxiliaries, for the treatment of malocclusions for which the appliance is most suitable. 2. Submission of five cases started by the preceptee showing progress to date. 3. A written review of the literature in a subject of the preceptee’s choice. 4. Oral or written examination, or both, to show a knowledge of the basic fundamentals of orthodontics.
Preceptorship
program
2 17
5. General idea and title of proposed thesis, which must be acceptable to the Qualifying Committee. Second-year examination to include : 1. Submission of Typodont with a second appliance of choice, the prcceptee to demonstrate a sound working knowledge of this appliance. 2. Resubmission of original five cases shown, with complete records showing progress to date. Submission of five additional cases under treatment by the preceptee, with complete records to date. 3. Oral or written examination, or both, to show advanced knowledge of clinical orthodontics and basic sciences, of the latter to the extent given in current textbooks. 4. A written review of the literature on a subject of the preceptcc’s choice. 5. Ontlinc of thesis. (Note: Definite progress should be evident at this time. It is the critical stage in the preceptee’s development. j Third-pear examination to include : 1. Comprehensive examination by the Qualifying Committee sitting as an examining board plus written examination to be based on anything pertaining to orthodontics with special reference to the literature of the last fifteen years. (Suggested: Dr. Philip Adams, etc.) 2. Thesis. This should be submitted sufficiently in advance to a.llow for reading by each member of the Committee. 3. Resubmission of ten cases previously shown, with complete records to clatcb,together with five additional cases treated by the prcccptce, with complete records to date. (No~P: Records of all cases submitted should include complete case analy.. sis, outline of treatment, and retention. All cases shown by t.hc prrceptcc should be named and numbered when first, presented. A record of these cases should be kept by the C0mmittee.j
I hereby make application to _---- -___ -_----------------_-____ ----__ Qualifying Committee for preceptorship tra.ining in accordance with its rules and regulations. I enclose $---------herewith. In making this application I agree that the ---_---_-__--_---__-__ - _------ -_~----~~ Qualifying (Yommittee may investigate my qualifications in whatever manner it sees fit, and may refuse to accept my application, or having accepted my application ma;\ have the right to suspend or discontinue my training program at any time. Its decisions shall be final and binding upon me and I shall not and will not question any such action in any court of law or other tribunal nor hold the said -----_---------_____-----Qualifying Committee liable in any manner, legal or otherwise, for any damages which may result from any of the above a&ions. ----------------------, precrptec Signed Date
218
AmericavL Association QUESTIONNAIRE
FOR
of Orthodontists
PRECEPTEES
In requesting permission from the _-____-_----___--_________ Society of Orthodontists to become a preceptee to one of our members, you have signified your intention of preparing yourself for membership in this organization. As an aid in determining your qualifications for the study of orthodontics will you please complete this questionnaire. Please feel free to supply any additional information you may have that is not provided for in the questionnaire.
1. Name in full -_---_---~~~~--~_-~--~~-~~----~~~-~~-~~--2. Address --___--___----_____ -_---_-3. Place and date of birth -- __-_ - -_______ --__ 4. Dental college attended _____ -- _-____-__ - __.. _-__ 5. Date of graduation -_-_-___- ____ ---_----__---6. Did you graduate
in the upper,
7. Other colleges attended
middle,
or lower one-third
of your class?
and degrees received --------_----_----_--------
8. Of what dental societies are you now or have you been a member (give dates of membership) -__-__------_-_---__---------9. Have you ever been engaged in the practice of dentistry _-- _---_ _----_--10. If so, give place and dates --------_-----_----_-------_----__----__--____-----------------------------------------------~---11. In what states are you licensed to practice ~~---__-~--_~-~_-~~_-~---~--~ 12. What are your reasons for wishing to study orthodontics ____-_ -- ____ -___ __~_~~--____--_-_----~----~~~~~-~~-~-----~~~-------~~----~----~-~-~~--~ 13. What is the name of the orthodontist with whom you are contemplating association _-___----__--_---__-____________________ 14. What financial arrangements have you made with the preceptor of your choice _-_-_--___-____-____-----------------------------------------.
15. Have you applied to any recognized dental school for graduate orthodontics __-_--_--_---~--~_-_____________________------~-~----~-~ 16. If so, what was the reply _----- -___ -----_-------_--------------------. ___________~___________________________-------------------------------_---_-----_----__---______________ Signature Date
work
in
QUESTIONNAlRE
FOR PRECEPTORS
By requesting permission from the _-_---_-_----__-____---_Society of Orthodontists for permission to act as a preceptor, you are assuming an Ohli@tion to give a course of instruction that will prepare a st,udent to become a competent orthodontist and one who will be able to qualify for membership in the American Association of Orthodontists. To assist the Admissions Cornmittee in determining your qualifications for this responsibility will you please complete this questionnaire in full. Please feel free to supply any additional iuformation you may have that is not provided for in this questionnaire. 1. Name in full ________________________ --___- ____ -_---___- -__-.-._- -----2. Business address _________________________ - ____ -__-_- _-__----_ ------3. Place and date of birth _____________ -_-__-- ____- --- __--_- ------------4. Dental college attended and date of graduat,ion ____- - _----_ ----..-----___-__-----5. Ot,her colleges attended and degrees reccivrd ______- ------- _-_-_ -_- .._._ ..-c-----__~~_~--___~-____________________~~~~~~~~~~~~~~~--~-~~--~~~~~~-_-------_--_______-_____________________------------------------------6. 7. 8. 9. IO. 11. I?. 13. 14. I5.
Have If so, Dates What Have If so, Dates Hours Have Name
you had graduate training in orthodontics ___---_-----_---_-----~at which school or university ______________ - ___-_ ---_- __-__-.-_- _you were in attendance ___- _________________ --_-- -_-_-_-.- ----_degree was earned, if any _-- ________ -__-_---_-_____---_-----you had postgraduate training in orthodontics __-_--- _-_____- - - - .-at which school or university ______________ ----_- --_-- --_-- .-.. -you were in attendance ___________________ - ____ -__------______.. per week in attendance __________________ -___-- ____ ---_-- -.___- you taken any refresher courses ___________ - ____ ___----_-__-- -_of courses and places given ___________________ -_--_-----_-_ ~--
16. By whom given and the dates _- __________________ 17. What other training
in orthodontics
--_---_----
have you had (give full details)
18. How many years were you in general prac%ice _--_-------__-----_-__ -19. Places and dates _____ ---_----__---_-_-_________________ 20. How many years have you been in the exclusive practice
___-__-_-_ ..--
-..-
____-__- ---_of orthodontics _.
21. Place of practice and dates ___---_-_-_-__----_-------------------.--22. Are you alone in practice or do you share an association ---__~---c~_-_-~ 23. If the latter, give full details -_--___-___-_-_---_---------_____ --- __..
220
American
Association
of
Orthodontists
Am.
J. Orthodontics
March1963
24. Are you a diplomate of the American Board of Orthodontics ____________ 25. Of what orthodontic societies are you now or have you been a member _-__ -----_-----_-----__---------------------------------------------------26. Give dates of membership __________ -___- ____ -__-_-__-- ______ -- ______ 27. Are you a member or have you been a member of any study clubs _- _-____ 28. Give name or organization and dates of membership -_-- _________-______ 29. Are you now or have you been a member of any scientific societies other than those directly connected with orthodontics __________------________ 30. Give name and dates of membership --_- ________ --_-- ____--_________31. Official positions held in dental, orthodontic, or other scientific societies -----------------_---__--------------------------------------------------32. Are you now or have you been interested in the field of research __-____-------_-------_--_-----------------------------------------------------33. What is or has been the area of special interest __--__-- _______________~_------------_--_______________________~~-~-~--~~~~~~~~~--~-~~-~~-~--~. 34. List of reports and where published -------__---_-_-_-c_-______-----_---__-___-_-_-_--__--_____________________--------------------------35. Have you read papers before scientific societies __------________-__- --36. Give names of societies, titles of papers, and dates published ____________ ~~_-__-_---__---_-______________________--~~---~-----~-~--~~~~--~~~~---. 37. Have you given clinics or other demonstrations before scientific societies _-__ __------_-------___-____________________~~-~--~~~~~~~-~~~~~~~~~-~-~~--~ 38. Give names of societies, titles of presentations, and date presented _______-
39. Have you taught in a dental or other school ---_--____ -- _________--_--40. Name of school or schools -_- ____________________________ -__-__-- ____ 41. Rank upon leaving _-__--_____------~-_-~-~~-~~-~---~~---~~----~~--42. Subjects taught __--_--_-- _______ -__-_- ____ ---_-_- ____ -__--_-___-_---. ----------------------------------------------------------------------43. Range of years -_______------_-__-_~--~~~~~--~.-~~-~-~----~~~-~-~~~~~. 44. Time devoted to teaching ----__-__----_--___-_________________ ____ --_ 45. Dates of employment --__---_-_---__---_-________ _____ ---__--- ____ --46. Have you ever given any courses of instruction outside of a dental school __ -----_--------_--___--------------------------------------------------47. If so, describe fully ---_--___-__-_______ - _____ ------_-___-_________ ---------_-----_----____________________--~~~~~~~-----~-~--~~~~~~~~~-~~ 48. Dates when such courses were given, place given, under whose auspices _-__ --____-_---_--_--_______________________~~--~~~~~~---~~-~--~~~~~~~~~~~~ 49. Qualifications for those in attendance -----__----__-____--_-__ -__----__ ______-----_-__--___---------------------------------------------------
Preceptorship
Volume 49 Wum her 3
program
22 1
50. Have you ever had an associate in your office _____-____-.---_---------51. If so, please give names and dates of association ------__--____---_ -..--.. _---~-___--_____________________________~~-~~~~~~~~~-~~~~~~--~-~---~~-5%. Do you practice in more than one location _-_------__-_-_ - _--- --..---53. If the answer is “yes,” give addresses of additional locations and time spent in each ________________________________________------_-_-__--_ 54. Do you employ a dental hygienist _____ - _____ -- ____ -_-__---____--_ _55. How many dental assistants, laboratory technicians, secretaries, or othc)r auxiliary help do you employ _--_--__-_-__-____ ----_- ________ -__.-_ _. 56. Do you have your own x-ray equipment - _____ ------_---_-_--___-_. _,557.Do you require cephalometric head films of your patients ___-- --_-_..-_. ._58. If so, for what purpose are they used _-_-___--------_-___ ---__- ___....59. Give in detail your proposed program
of study (by years) for the prereptee
60. Describe your type of treatment, diagnosis, and your general approach to orthodontic procedures as practiced in your office ---_--_ - __-___--I___
61. What is the average number of new cases pou have started in the last five ~-ears__---_---____-____--____________________------------------62. What is your reason for requesting permission 1.0 assume the responsibilit> of training a preceptee -__--_--__--__-----_--__-- __--__---------...63. What financial
arrangement
do you propose to arrange with him -_ -__..-_
_----~-__-------___--~~-----~~-~~~-~~~---~~--~----~--~-~~----~~~--~---~ 64. Will you be responsible for the completion of the treatment of any cases hc undrrtakes while associated with you --~~_~~~------~-------~~ -_-. ___--_--_~~-~~--___~~---~~~---~~-~~~~~-~~~~----~--~~-~-~~-~~-~~~-~~~~~65. What, is the name of the preceptee you are proposing to teach ---_-_ _- --.
~~_-__~_----~~~-----____________ Signature Date