Dental Hygiene License Application Packet 645 088 645135
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Dental Hygiene License Application Packet Contents: 1. 645-135.....Contents List/SSN Information/Mailing Information............................ 1 page 2. 645-145.....Application Instructions Checklist.......................................................4 pages 3. 645-137.....License Requirements...................................................................... 2 pages 4. 645-090.....Dental Hygiene License Application...................................................5 pages 5. 645-117......Dental Hygiene Expanded Functions Education Information/AIDS Education Information............................................. 1 page 6. 645-089.....Education Verification.......................................................................... 1 page 8. 645-115......Out-of-State Credential Verification Form..........................................2 pages 9. 645-127.....Qualifying Examinations for License..................................................2 pages 10. DANB.........Dental Hygiene Law Examination Fact Sheet, Law Exam Application, Application Agreement, and Special Accommodations Form..........10 pages 11. RCW/WAC and Online Website Links................................................................... 1 page Important Social Security Number Information: You are required by state and federal law to provide a social security number with your application. If you do not have a social security number at the time you send in this application, please read, complete, and return this form with your application. A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be substituted. In order to process your request: Mail your application with initial documentation and your check or money order payable to: Send other documents not sent with initial application to: Department of Health P.O. Box 1099 Olympia, WA 98507-1099 Dental Hygiene Credentialing P.O. Box 47877 Olympia, WA 98504-7877 Contact us: 360-236-4700 DOH 645-135 March 2017 (This page intentionally left blank.) Application Instructions Checklist You should use this application to obtain a dental hygiene license if you have completed an approved dental hygiene education program. The program must be currently accredited or received initial accreditation by the American Dental Association Commission on Dental Accreditation (CODA) on or before June 30, 2007. The program must have included the following curriculum: a. Didactic and clinical competency in the administration of injections of local anesthetic, which includes infiltration: ASA, MSA, Nasopalatine, greater palatine. Block: Long buccal, mental, inferior alveolar and PSA. b. Didactic and clinical competency in the administration of nitrous oxide analgesia. c. Didactic and clinical competency in the placement of restorations into cavities prepared by a dentist. d. Didactic and clinical competency in the carving, contouring and adjusting contacts and occlusions of restorations. If your program did not include the above curriculum: • • You may complete a Washington State approved expanded function education program(s) to meet this requirement. A list of approved expanded function education programs is enclosed in this application. You may qualify for the initial limited license. There is a separate initial limited license application. See the requirements for an initial limited license on our website. Important background check Information: Washington State law authorizes the Department of Health to obtain fingerprint-based background checks for licensing purposes. This check may be through the Washington State Patrol and the Federal Bureau of Investigation (FBI). This may be required if you have lived in another state or if you have a criminal record in Washington State. This would be at your own expense. All information should be printed clearly in ink. It is your responsibility to submit the required forms. FF Application Fee. This fee is non-refundable. You can check the online fee page for current fees. FF Check if either apply: Request for Military Training and Experience Evaluation Spouse or Registered Domestic Partner of Military Personnel FF 1. Demographic Information: Social Security Number: You must list your social security number on your application. Please call the Customer Service Center at 360-236-4700 if you do not have one. DOH 645-146 March 2017 Page 1 of 4 National Provider Identifier Number (NPI): The National Provider Identifier (NPI) is a standard unique identifier for health care professionals available from the Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identifier. If you have a NPI number, provide this on your application. Legal Name: List your full name: first, middle, and last. Definition of legal name: “Legal name” is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court. The court must have the legal authority to change your name. We may ask you to prove your legal name. If you use any name other than your legal name on this form, your application may be denied. Birth date: Provide your month, day and year of birth. Birth place: Provide the city, state and country where you were born. Address: List the address we should use to send any information about your license. Be sure to include the city, state, zip code, county, and country. This will be your permanent address with the Department of Health until we have been notified of a change. See WAC 246-12-310. Phone, Fax and Cell Numbers: Enter your phone, fax and cell numbers, if you have them. Email: Enter your email address, if you have one. Other Name(s): Indicate whether you are known or have been known under any other names. If you have a name change, you must notify the Department of Health in writing. You must include proof of this change. See WAC 246-12-300. FF 2. Personal Data Questions: All applicants must answer the same personal data questions. They are focused on your fitness to practice the essential skills of this profession. If you answer “yes” to any questions in this section, you must provide an appropriate explanation. You must also provide the documentation listed in the note after the question. If you do not provide this, your application is incomplete and it will not be considered. • • Question 5 includes misdemeanors, gross misdemeanors and felonies. You do not have to answer yes if you have been cited for traffic infractions. You can get copies of court records through the county courthouse where the conviction, plea, deferred sentence, or suspended sentence was entered. If you have been granted certificate(s) of restoration of opportunity, please provide a certified copy of each certificate. • Another jurisdiction means any other country, state, federal territory, or military authority. FF 3. Education: List in date order, most recent to later, all of your educational preparation and postgraduate training. Attach additional completed pages if you need more space. Transcripts: Graduation from an American Dental Association Commission on Dental Accreditation (CODA) dental hygiene education program is the approved education for license. Have your school send official school transcripts directly to the Department of Health. DOH 645-145 March 2017 Page 2 of 4 FF 4. Examination: Check all the dental hygiene examinations you have taken. The following examinations are the approved examinations for license. • • Dental Hygiene National Board examination. Washington State Drug and Law exam administered by Dental Assisting National Board, Inc. • Western Regional Examining Board (WREB) Hygiene Success Card or Central Regional Dental Testing Service (CRDTS) or Commission on Dental Competency Assessments (CDCA) formally known as the NERB passing examination scores. The CDCA (NERB) examination is only accepted for the time period of 01/01/2000–08/21/2009. • WREB Anesthesia examination. • WREB Restorative examination. • CRDTS Restorative examination if passed after March 7, 2016. FF 5. Experience: List in date order, most recent to later, all of your professional experience and practice from date of graduation from professional college. Attach additional completed pages if you need more space. FF 6. Other License, Certification, or Registration: List all states, including Washington, where credentials are or were held. List all active, inactive, and expired credentials. Attach additional pages if you need more space. The out-of-state credential verification form is provided in this packet. FF 7. AIDS Education and Training Attestation: Read the AIDS education and training attestation. AIDS training may include selfstudy, direct patient care, courses, or formal training. A minimum of seven hours is required. Course content can be found in WAC 246-12-270. If AIDS education was included in your professional education or training, an additional course is not required. FF 8. Applicant’s Attestation: You must sign and date this for us to process the application. DOH 645-145 March 2017 Page 3 of 4 For Spouses and Registered Domestic Partners of Military Personnel Being Transferred or Stationed in Washington: Under state law, if you are the spouse or state-registered domestic partner of a servicemember of any branch of the U.S. Military, to include Guard or Reserve, and are applying for a health care professional credential in this state, you may be eligible to have the processing of your application expedited to receive your credential more quickly. Documents to submit with your application should include the following: • • A copy of your spouse’s or registered domestic partner’s military transfer orders to Washington State. One of the following: -- A copy of your marriage certificate to show proof of marriage; or -- A copy of a state’s declaration or registration showing you are in a state registered domestic partnership with a member of the U.S. military. For Current and Former Servicemembers Requesting Evaluation of Military Training and Experience Under state law, your military education, training, and experience may count towards attaining certain civilian health care profession credentials in Washington State. Submitted information will be reviewed by the Department of Health to determine substantial equivalency for meeting the credentialing requirements in this state. Documents to submit with your health care professional credential application should include the following: • • • • If applicable, a copy of your DD214 Certificate of Release or Discharge from Active Duty, Member-4 or service 2 copy, or NGB-22 for National Guard. Please note: -- A copy of your DD214 can be downloaded from the EBenefits website. -- You can request a replacement copy of your NGB-22 on the National Archives website. Official Joint Service Transcript (JST) or Community College of the Air Force(CCAF) Transcripts. Please note: -- JST can be sent electronically by visiting the JST website and selecting Washington State Department of Health. -- CCAF transcripts cannot be sent electronically. See the CCAF website for transcript information. Verification of Military Experience and Training (VMET) or DD Form 2586. See the DoDTAP website. If applicable, application for the Evaluation of Learning Experiences During Military Service (DD Form 295). See the Military Resources website. DOH 645-145 March 2017 Page 4 of 4 License Requirements Thank you for applying to become a licensed dental hygienist in Washington State. To expedite the license process, please use the following checklist. FF Verification of exams: • Western Regional Examining Board (WREB) Hygiene Success Card or Central Regional Dental Testing Service (CRDTS) or Commission on Dental Competency Assessments (CDCA) formally known as the NERB passing examination scores The CDCA exam is only accepted for the time period of 01/01/2000–08/21/2009. • WREB Anesthesia Success Card • WREB or CRDTS Restorative Success Card A certification of your scores is needed directly from WREB/CRDTS/CDCA(NERB) of each exam. Note: WREB/CRDTS/CDCA(NERB) may charge a processing fee. Please contact them prior to your request to prevent a delay. Western Regional Examining Board 23460 North 19th Avenue, Suite 210 Phoenix, AZ 85027. 602-944-3315 Central Regional Dental Testing Service, Inc. 1725 SW Gage Blvd Topeka, KS 66604-3333 785-273-0380 Commission on Dental Competency Assessments 1304 Concourse Drive, Suite 100 Linthicum, MD 21090 301-563-3300 Verification of your Washington State Dental Hygiene Drug and Law Exam. The examination includes questions on legend (prescription) drugs and dental hygiene and dental laws and rules for Washington State. • • • • A minimum score of 90 percent is required. Dental hygiene laws and rules are located in RCW 18.29 and WAC 246-815. Dental laws and rules are located in RCW 18.32 and WAC 246-817. Dental Assisting National Board, Inc. gives the exam. An application to apply for this examination is enclosed. Verification(s) will only be accepted when received by the department directly from the source. These items should not be included with your application. DOH 645-137 March 2017 Page 1 of 2 FF Out-of-State Credential Verification A verification/certification from any state you have been credentialed in must be sent directly to the Department of Health. Requirements for License by Interstate Endorsement of Credentials In addition to meeting all the requirements listed above (Requirements for Dental Hygienists) you must meet the following: FF Pay the credentialing application fee. FF You have a nonlimited license by examination in another state. The other state’s current licensing standards must be substantially equivalent to Washington State. Review WAC 246-815-100 to determine if your state may meet this requirement. FF You have a current license in another state and have been engaged in clinical practice with in the previous year as a dental hygienist. Note: Some applicants do not qualify for license by interstate endorsement. However, these same applicants may qualify for the initial limited license. There is a separate initial limited license application located on our website. Other Information Criminal history checks are conducted for all license applicants. If you answered yes to any of the personal data questions, please submit the appropriate supporting documentation as indicated on the application. If your application is incomplete, you will be mailed a letter regarding the deficiencies. • The application is considered incomplete if requested information is left blank. Write N/A or place a line through section instead of leaving blank. • A courtesy renewal notice will be mailed to your address on record. You must keep your address current with us. Any renewal postmarked or presented to the department after midnight on the expiration date is late. • Information regarding the dental hygiene program is available on our website. Note: You cannot practice dental hygiene until your license is issued. DOH 645-137 March 2017 Page 2 of 2 Date Stamp Here Revenue: 0251040000 Dental Hygiene Application Select if either apply: c Request for Military Training and Experience Evaluation c Spouse or Registered Domestic Partner of Military Personnel Select One: License by examination License by endorsement of credentials and examination 1. Demographic Information Social Security Number (SSN) (If you do not have a SSN, see instructions) Name First National Provider Identifier Number (NPI) (Enter 10 digit number) Middle Birth date (mm/dd/yyyy) Last City Male Female Place of birth State Country Address City State Zip Code County Country Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #) Email address: Mailing address if different from above address of record City State Zip Code County Country Note: The mailing and email addresses you provide will be your addresses of record. It is your responsibility to maintain current contact information on file with the department. Have you ever been known under any other name(s)? Yes No If yes, list name(s): Will documents be received in another name? Yes No If yes, list name(s): Dental Hygiene School Year graduated Approved dental hygiene expanded functions program? Yes No Date approved DOH 645-090 March 2017 Page 1 of 5 2. Personal Data Questions Yes No 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? If yes, please attach explanation......................................... “Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disabilities, emotional or mental illness, specific learning disabilities, HIV disease, tuberculosis, drug addiction, and alcoholism. If you answered yes to question 1, explain: 1a. How your treatment has reduced or eliminated the limitations caused by your medical condition. 1b. How your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. Note: If you answered “yes” to question 1, the licensing authority will assess the nature, severity, and the duration of the risks associated with the ongoing medical condition and the ongoing treatment to determine whether your license should be restricted, conditions imposed, or no license issued. The licensing authority may require you to undergo one or more mental, physical or psychological examination(s). This would be at your own expense. By submitting this application, you give consent to such an examination(s). You also agree the examination report(s) may be provided to the licensing authority. You waive all claims based on confidentiality or privileged communication. If you do not submit to a required examination(s) or provide the report(s) to the licensing authority, your application may be denied. 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? If yes, please explain..................................... “Currently” means within the past two years. “Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally. 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism?................................................................................................................................................ 4. Are you currently engaged in the illegal use of controlled substances?.................................................... “Currently” means within the past two years. Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine) not obtained legally or taken according to the directions of a licensed health care practitioner. Note: If you answer “yes” to any of the remaining questions, provide an explanation and certified copies of all judgments, decisions, orders, agreements and surrenders. The department does criminal background checks on all applicants. 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction?.... Note: If you answered “yes” to question 5, you must send certified copies of all court documents related to your criminal history with your application. If you do not provide the documents, your application is incomplete and will not be considered. If you have been granted certificate(s) of restoration of opportunity, please provide a certified copy of each certificate. To protect the public, the department considers criminal history. A criminal history may not automatically bar you from obtaining a credential. However, failure to report criminal history may result in extra cost to you and the application may be delayed or denied. DOH 645-090 March 2017 Page 2 of 5 2. Personal Data Questions (cont.) Yes No 6. Have you ever been found in any civil, administrative or criminal proceeding to have: a. Possessed, used, prescribed for use, or distributed controlled substances or legend drugs in any way other than for legitimate or therapeutic purposes?.................................................... b. Diverted controlled substances or legend drugs?................................................................................. c. Violated any drug law?.......................................................................................................................... d. Prescribed controlled substances for yourself?..................................................................................... 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a health care profession? If “yes”, please attach an explanation and provide copies of all judgments, decisions, and agreements?.................................................................. 8. Have you ever had any license, certificate, registration or other privilege to practice a health care profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority?............... 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority?................................................................................ 10. Have you ever been named in any civil suit or suffered any civil judgment for incompetence, negligence, or malpractice in connection with the practice of a health care profession?.......................... 11. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)?.................................................................................................... 3. Education List in date order, most recent to later, all of your educational preparation. Attach additional completed pages if you need more space. Schools Attended Full Name, City and State Degree Earned Attendance Dates Start End (mm/yyyy) (mm/yyyy) DOH 645-090 March 2017 Page 3 of 5 4. Examination The examinations listed below are the approved examinations for licensure. Check all that you have taken. FF Dental Hygiene National Board examination. Date of exam: ___________________________ (mm/dd/yyyy) FF Washington State Drug and Law exam (administered by Dental Assisting National Board, Inc.). Date of exam: ___________________________ (mm/dd/yyyy) FF WREB Patient Evaluation/Prophylaxis. Date of exam: ___________________________ (mm/dd/yyyy) FF WREB Anesthesia examination. Date of exam: ___________________________ (mm/dd/yyyy) FF WREB Restorative examination. Date of exam: ___________________________ (mm/dd/yyyy) FF CRDTS Restorative examination if passed after March 7, 2016. Date of exam: ___________________________ (mm/dd/yyyy) FF CRDTS Patient Evaluation/Prophylaxis. Date of exam: ___________________________ (mm/dd/yyyy) FF CDCA (NERB) Patient Evaluation/Prophylaxis. Date of exam: ___________________________ (mm/dd/yyyy) Please note: The CDCA (NERB) is only accepted for the time period of January 1, 2000 to August 21, 2009. 5. Experience List in date order, most recent to later, all of your professional experience and practice from date of graduation from professional college. Include the month/day/year. Attach additional pages if you need more space. Total Number of Months Name of Business Dates Start mm/yyyy End mm/yyyy 6. Other License, Certification, or Registration List all states where credentials are or were held. Attach additional completed pages if you need more space. State/ Jurisdiction Profession Certificate Year issued Number Permanent or Temporary Currently in force No Yes No Yes No Yes No Yes No Yes DOH 645-090 March 2017 Page 4 of 5 7. AIDS Education and Training Attestation I certify I have completed the minimum of seven hours of education in the prevention, transmission and treatment of AIDS. This includes the topics of etiology and epidemiology, testing and counseling, infection control guidelines, clinical manifestations and treatment, legal and ethical issues to include confidentiality, and psychosocial issues to include special population considerations. I understand I must maintain records documenting said education for two years and be prepared to submit those records to the department if requested. I understand if I provide any false information, my license may be denied, or if issued, suspended or revoked. If AIDS education was included in your professional education or training, an additional course is not required. Applicant’s Initials Date 8. Applicant’s Attestation I, _________________________________________ , declare under penalty of perjury under the laws of (Print applicant name clearly) the state of Washington the following is true and correct: • I am the person described and identified in this application. • I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disciplinary Act. • I have answered all questions truthfully and completely. • The documentation provided in support of my application is accurate to the best of my knowledge. • I have read all laws and rules related to my profession. I understand the Department of Health may require more information before deciding on my application. The department may independently check conviction records with state or federal databases. I authorize the release of any files or records the department requires to process this application. This includes information from all hospitals, educational or other organizations, my references, and past and present employers and business and professional associates. It also includes information from federal, state, local, or foreign government agencies. I understand I must inform the department of any past, current or future criminal charges or convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability to provide quality health care. If requested, I will authorize my health providers to release to the department information on my health, including mental health and any substance abuse treatment. Dated ___________________________ at _______________________________________________ (mm/dd/yyyy) (City, state) By: _______________________________________________________________________________ (Signature of applicant) DOH 645-090 March 2017 Page 5 of 5 (This page intentionally left blank.) Dental Hygiene Expanded Functions Education Information Applicants interested in taking approved expanded function courses in preparation for Washington State Dental Hygiene License, may contact the schools listed below for courses which may include local anesthetic, nitrous oxide/oxygen analgesia and restorative dentistry. Pierce College Fort Steilacoom Lakewood, WA Contact Phone—253-964-6248 Contact email—vm-dentalinstitute@pierce.ctc.edu Summer Course (August—Anesthetic, Nitrous Oxide and Restorative) Lake Washington Institute of Technology Kirkland, WA Contact the Dental Hygiene Department: Beth Davis at 425-739-8386 or Monta Frost, Director at 425-739-8404 Winter (Anesthetic and Nitrous Oxide) Summer (Anesthetic and Nitrous Oxide) Eastern Washington University Cheney, WA Contact Phone—509-828-1300 Contact email—awetmore@ewu.edu Phoenix College Phoenix, AZ Contact Nan Reif, Director, Center for Health Professions 602-285-7331 Classes available in May and in the Fall (Anesthetic and Nitrous Oxide) Oregon Health & Science University Portland, OR Contact Debbie Reaume, Continuing Education Program 503-494-8857 Contact school for class date and times (Nitrous Oxide) Portland Community College Institute for Health Professionals Portland, OR Contact Bem Hanamoto, 971-722-6627 Contact email—bem.hanamoto@pcc.edu www.pierce.ctc.edu www.ewu.edu (Restorative) www.pcc.edu/climb/health (Restorative) AIDS Education Information Following are possible contacts for information on available AIDS Education Classes for dental hygienists: Class Other Sources Clark College InfoNet Workforce Development and Continuing Education Red Cross 1800 East McLoughlin Blvd., Mail Stop: 6 Local Fire Department Vancouver, Washington 98663 Department of Health Online 360-992-2939 Resources Page DOH 645-117 March 2017 (This page intentionally left blank.) Dental Hygiene Credentialing P.O. Box 47877 Olympia, WA 98504-7877 360-236-4700 Dental Hygiene Education Verification Note: this form must be submitted directly from the Dental Hygiene program. Applicant Information: Name First Middle Last Date of Birth Address State City Zip Code To be completed by the dental hygiene program: The student listed above has graduated or successfully demonstrated the following at ____________________________________________________ on ________________________________ Name of program (mm/dd/yyyy) which is a dental hygiene program accredited or approved by the following: c Expanded functions education program approved by the Secretary of the Department of Health. c The American Dental Association Commission on Dental Accreditation for dental hygiene. c The Commission on Dental Accreditation of Canada (CDAC) for dental hygiene. Please check the answers applicable to this student. Please note clinical competency means on live patients. Yes No a. Didactic and clinical competency in the administration of injections of local anesthetic, which includes infiltration: ASA, MSA, Nasopalatine, greater palatine. Block: Long buccal, mental, inferior alveolar, and PSA; b. Didactic and clinical competency in the administration of nitrous oxide analgesia; c. Didactic and clinical competency in the placement of restorations into cavities prepared by a dentist; and d. Didactic and clinical competency in the carving, contouring, and adjusting contacts and occlusions of restorations. Program Director Name (Please print) School Seal Signature of Program Director Date DOH 645-089 March 2017 (This page intentionally left blank.) Dental Hygiene Credentialing P.O. Box 47877 Olympia, WA 98504-7877 360-236-4700 Out-of-State Credential Verification To Applicant: Please complete this side of this form and send it to the state(s), jurisdiction(s) or Canadian provinces where you are or have been licensed, certified, or registered as a healthcare provider. The regulatory agency will complete pages two and three. Name: Last First Middle Mailing Address City State Zip Code Phone (enter 10 digit #) Cell (enter 10 digit #) Email address Any other names used Type of license(s) you hold or have held in other state(s), jurisdiction(s) or Canadian provinces Washington State healthcare credential type you are applying for Washington State healthcare credential number (if available) Date Issued Have the licensing agency complete page two and return this form to the address listed above. If you have any questions, please call 360-236-4700. This form may be duplicated. DOH 645-115 March 2017 Page 1 of 3 (To be Completed by the Regulatory Agency) Please complete this form regarding the applicant listed on the reverse. Submit the completed form and any other requested material directly to this office at the address on the reverse. We will not accept the form if submitted by the applicant. Thank you. Name of license, certification, or registration holder: Authority providing verification: (state, jurisdiction or Canadian province, name, and title) Applicant was credentialed by: Date: Score: FF Written Examination Name of examination: FF Other Examination Date: Score: Name of examination: Is credential current: c Yes No Expiration Date: Is this individual considered to be in good standing in your state or Canadian province? Yes No If “no,” please attach explanation. Has this credential ever been denied? Yes Suspended? Yes Revoked? Yes Surrendered? Yes Reinstated? Yes No No No No No If “yes,” please provide a copy of the final order or other documentation of action taken. If this credential holder has been disciplined, has he/she successfully completed all requirements and is currently in good standing? Yes No Signature: Official Seal Title: Date: DOH 645-115 March 2017 Page 2 of 3 (To be Completed by the Regulatory Agency) As of July 2006, the following states are not approved by the Washington State Dental Hygiene Program to have a substantially equivalent scope of practice: • Delaware, • Indiana, • Kentucky, • New York. The state, jurisdiction, or Canadian province of ______________________________________ allows the following scope of dental hygiene practice: Yes _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ No _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) Oral inspection and measuring of periodontal pockets; Patient education in oral hygiene; Taking intra-oral and extra-oral radiographs; Applying topical preventive or prophylactic agents; Polishing and smoothing restorations; Oral prophylaxis and removal of deposits from the surface of the teeth; Recording health histories; Taking and recording blood pressure and vital signs; Performing subgingival and supragingival scaling; and Performing root planing. I further certify this information is true and correct to the best of our knowledge. Authority Providing Verification_________________________________ State, jurisdiction or Canadian province Official State or Canadian Province Seal Name_____________________________________________________ Signature__________________________________________________ Title_______________________________________________________ Date______________________________________________________ This Form May Be Duplicated DOH 645-115 March 2017 Page 3 of 3 (This page intentionally left blank.) Qualifying Examinations for License for Dental Hygienists in Washington State Region State....................... Qualifies For: Western Regional Alaska..................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Examining Board Arizona................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) (WREB) California................ Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Hawaii..................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Idaho...................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Illinois..................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Kansas................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Missouri.................. Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Montana................. Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Nevada................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) New Mexico............ Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) North Dakota.......... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Oklahoma............... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Oregon................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Texas...................... Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Utah........................ Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Wyoming................ Patient Evaluation / Prophylaxis (Restorative or Anesthetic—if taken) Central Regional Alabama................. Patient Evaluation / Prophylaxis Dental Testing California................ Patient Evaluation / Prophylaxis Service Colorado................. Patient Evaluation / Prophylaxis (CRDTS) Georgia................... Patient Evaluation / Prophylaxis Hawaii..................... Patient Evaluation / Prophylaxis Illinois..................... Patient Evaluation / Prophylaxis Iowa........................ Patient Evaluation / Prophylaxis Kansas................... Patient Evaluation / Prophylaxis Minnesota............... Patient Evaluation / Prophylaxis Missouri.................. Patient Evaluation / Prophylaxis Nebraska................ Patient Evaluation / Prophylaxis New Mexico............ Patient Evaluation / Prophylaxis North Dakota.......... Patient Evaluation / Prophylaxis South Carolina........ Patient Evaluation / Prophylaxis South Dakota.......... Patient Evaluation / Prophylaxis West Virginia.......... Patient Evaluation / Prophylaxis Wisconsin............... Patient Evaluation / Prophylaxis Wyoming................ Patient Evaluation / Prophylaxis DOH 645-127 March 2017 Page 1 of 2 Commission on Connecticut............ Patient Evaluation / Prophylaxis Dental Competency Florida.................... Patient Evaluation / Prophylaxis Assessments (CDCA) Hawaii..................... Patient Evaluation / Prophylaxis formally knownsx as Illinois..................... Patient Evaluation / Prophylaxis NERB Indiana.................... Patient Evaluation / Prophylaxis Kentucky................. Patient Evaluation / Prophylaxis Only accepted for Maine...................... Patient Evaluation / Prophylaxis the time period of Maryland................. Patient Evaluation / Prophylaxis January 1, 2000 to Massachusetts....... Patient Evaluation / Prophylaxis August 21, 2009 Michigan................. Patient Evaluation / Prophylaxis Mississippi.............. Patient Evaluation / Prophylaxis Nevada................... Patient Evaluation / Prophylaxis New Hampshire...... Patient Evaluation / Prophylaxis New Jersey............. Patient Evaluation / Prophylaxis New Mexico............ Patient Evaluation / Prophylaxis New York................ Patient Evaluation / Prophylaxis Ohio........................ Patient Evaluation / Prophylaxis Oregon................... Patient Evaluation / Prophylaxis Pennsylvania.......... Patient Evaluation / Prophylaxis Rhode Island.......... Patient Evaluation / Prophylaxis Vermont.................. Patient Evaluation / Prophylaxis Washington DC...... Patient Evaluation / Prophylaxis West Virginia.......... Patient Evaluation / Prophylaxis Wisconsin............... Patient Evaluation / Prophylaxis Region State....................... Qualifies For: Southern Regional Arkansas................ Does not qualify Testing Agency Kentucky................. Does not qualify (SRTA) South Carolina........ Does not qualify Tennessee.............. Does not qualify Virginia................... Does not qualify West Virginia.......... Does not qualify Individual States California................ Does not qualify Delaware................ Does not qualify Florida.................... Does not qualify Indiana.................... Does not qualify Missouri.................. Does not qualify Nevada................... Does not qualify Council of Interstate Alabama................. Does not qualify Testing Agencies Louisiana................ Does not qualify (CITA) Mississippi.............. Does not qualify North Carolina........ Does not qualify West Virginia.......... Does not qualify DOH 645-127 March 2017 Page 2 of 2 This exam application packet includes the application for the following exam: • Washington State Dental Hygiene Drug and Law (WSJ) DANB accepts 2018 applications through Dec. 31, 2018. Washington State Dental Hygiene Drug and Law Exam This application packet provides information concerning the Washington State Dental Hygiene Drug and Law (WSJ) exam required for Dental Hygienist licensure in the state of Washington. The following links to Washington state websites are included as reference points for candidates who wish to prepare for the Washington State Dental Hygiene Drug and Law exam: Dental Hygiene Law in the state of Washington: http://apps.leg.wa.gov/RCW/default.aspx?cite=18.29 The WSJ Exam is administered by the Dental Assisting National Board, Inc. (DANB) under an agreement with the Washington State Department of Health (WSDOH). This exam consists of 20 items covering the Washington State Dental Hygiene Practice Act, Dental Regulations for the State of Washington and legend (Prescription) drugs. Administrative Procedures and Requirements for credentialed health care providers in the state of Washington: http://apps.leg.wa.gov/wac/default.aspx?cite=246-12 Dental Hygiene Rules in the state of Washington: http://apps.leg.wa.gov/WAC/default.aspx?cite=246-815 Exams are administered in a computerized format at any of the national test centers contracted by DANB. Candidates are given 45 minutes to complete the 20-item exam. Pertinent sections of the act, regulations, and prescription drug references appear on the computer screen adjacent to each test question. Dental Rules in the state of Washington: http://apps.leg.wa.gov/wac/default.aspx?cite=246-817 Washington State Department of Health: http://www.doh.wa.gov/ Testing Timeline Start Submit exam application, documentation, fees 1-2 weeks Exam application is processed (if the application is incomplete, DANB will attempt to contact you for missing information) 1-2 weeks Test Admission Notice (with instructions to schedule your exam) is available in your online DANB account and mailed to your address on record 60-day testing window Visit www.vue.com/danb to schedule your exam appointment. Take exam and received preliminary exam result 2-3 weeks from exam date Receive official exam result at test center* *Each week, DANB submits official candidate results to the WSDOH on behalf of all candidates that tested. © 2018 Dental Assisting National Board, Inc. The DANB logo is a registered trademark of the Dental Assisting National Board, Inc. (DANB). NELDA®, CDA®, COA®, CRFDA®, CPFDA®, CDPMA®, COMSA®, DANB®, and Dental Assisting National Board® are registered certification marks of DANB. RHS®, ICE®, and Measuring Dental Assisting Excellence® are registered service marks of DANB. CERTIFIED DENTAL ASSISTANT™ is a certification mark of DANB. Mark of Dental Assisting Excellence™ is a service mark of DANB. Use of these marks is strictly prohibited, except as provided in the Usage Guidelines for DANB Trademarks, without the express written permission of DANB. 2 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene Drug and Law Exam • Applying for an Exam Expired exam application Submitting an Exam Application Exam applications must be mailed or faxed to DANB. The candidate should read this packet to ensure a completed application is submitted with all required documents and fees. Duplicate Exam Application If two applications are received for the same exam, completed applications will be processed, and duplicate payments will be returned, minus the $75 nonrefundable application fee, within 30 days, after the payment clears. Signing and dating the application is required. By signing and dating the application, the candidate affirms that the application and documentation are accurate and that the candidate agrees to abide by all applicable DANB policies described in this packet, including the Application Statements on page 6. The signature also allows DANB to release exam results to state regulatory agencies. Group Testing Groups of six or more candidates may request to take any DANB exam on the same day, at the same test center location. Download the Group Testing Form from www.danb. org for more information. Candidates with Disabilities DANB exams are designed to provide an equal opportunity for each candidate to demonstrate their knowledge-based competency. The exam will be administered to best ensure that it accurately reflects a candidate’s aptitude, achievement levels or other skills intended to be measured, rather than reflecting a candidate’s impaired sensory, manual or speaking skills except where those skills are factors the exam purports to measure. Payment Instructions DANB accepts payment by check, money order or credit card (Visa, MasterCard, American Express or Discover). Check or money order payments must be payable to DANB in U.S. dollars, must be written in English, must include the candidate name and must be mailed with the exam application. The application is a contract to test, and the check or credit card authorization is the contract to pay. DANB adheres to the provisions outlined in the Americans with Disabilities Act. In accordance with this act, DANB will make every reasonable effort to offer the exams in a manner that is accessible to people with documented disabilities. If auxiliary aids or alternative arrangements are required, DANB will attempt to make the necessary provisions, unless providing such would fundamentally alter the measurement of skills and knowledge the exam is intended to test, would result in undue burden, or would provide an unfair advantage to the disabled candidate. Returned Checks If a check is returned by the bank for any reason (including but not limited to nonsufficient funds, stop payment, closed account or refer to maker), DANB will notify the candidate and assess a $25 nonsufficient funds (NSF) fee to the account. The candidate will not be allowed to take the exam until a cashier’s check or money order for the full application and exam fee plus the $25 NSF fee has been received. If full payment has not been received within 30 days, the application will be null and void and the candidate’s account will remain on finance hold. The candidate must pay $100 (the $25 NSF fee and $75 nonrefundable processing fee) before DANB will remove the finance hold and process any exam application. No new business will be allowed for the candidate until the finance hold has been removed. The candidate must submit the Reasonable Accommodations Request forms (found on www.danb.org) and the required documentation, specifying exactly what aid or modification is requested by a physician or psychologist, with the exam application. DANB will only accept the forms found on www.danb.org. DANB reserves the right to authorize the use of auxiliary aids or modifications in such a way as to maintain the exam integrity and security. DANB exams are administered only in the English language. Modifications will not be approved for a candidate who requests accommodations because English is a second language. Incomplete Exam Applications It is the responsibility of the candidate to ensure the application is complete. If an application is incomplete, a letter indicating the reasons for the incomplete application will be sent to the candidate and the payer (if different). A refund for the exam/certificate fee, minus any stated nonrefundable fees, will be sent within 30 days of notice of the incomplete application. Refunds will be made only to the payer. An exam application is considered incomplete for reasons including but not limited to: • Missing information (e.g., candidate and/or payment information) • Appropriate documentation is not enclosed • No date or signature • Insufficient payment DANB’s Nondiscrimination Policy DANB does not discriminate in application, examination or certification activities on the basis of age, sex, gender identity, marital status, race, color, religion, national origin, sexual orientation or disability. 3 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene Drug and Law Exam Retaking a Passed Exam DANB certificants/candidates may take and pass DANBadministered exams only once unless directed to retake the exam by DANB staff in order to reinstate a certification(s) or to meet state regulatory agency requirements. Candidates from the state of New Mexico may take and pass the RHS exam no more than two (2) times in a 12-month period. Scheduling an Exam Appointment The candidate should schedule the exam appointment as soon as he/she receives or downloads the Test Admission Notice. The Test Admission Notice includes instructions to schedule the exam appointment at a Pearson VUE location. To find the nearest test center, visit www.vue.com/danb. Any candidate who applies to take a DANB exam and has previously passed that exam will be in violation of this policy and will have the application denied and will be issued a refund minus the nonrefundable application fee. Test centers may have limited availability; appointments are scheduled on a first-come, first-served basis. DANB cannot guarantee the availability of specific test center locations, dates or times; changes to test center locations and/or hours may occur without notice. Retaking a Fail Exam If a candidate takes more than one component exam in a single sitting but does not pass all the component exams, the candidate only needs to reapply for and retake the failed component exam(s) with a new application, required documentation and fees. State laws may require additional education after failed attempts. There is no limit on how many times a candidate may retake a failed exam. Exam Appointment Confirmation After the exam appointment is scheduled, Pearson VUE will send an appointment confirmation by email (if the email address was provided) or by regular mail. Candidates should read all email and mail from Pearson VUE, as it will contain important information regarding the exam appointment. Contact Pearson VUE to request a duplicate appointment confirmation notice. Scheduling a DANB Exam Rescheduling an Exam Appointment To reschedule an exam appointment within the 60-day testing window, the candidate must contact Pearson VUE. The candidate may reschedule an exam appointment up to 24 hours before the scheduled exam start time at no additional fee. See the Test Admission Notice for Pearson VUE contact information. Receiving the Test Admission Notice Candidates will be sent a Test Admission Notice within three to four weeks of submitting a completed exam application. The Test Admission Notice may also be downloaded through the candidate’s online DANB account. The Test Admission Notice will include instructions to schedule the exam appointment. Requesting a New Testing Window If a candidate cannot schedule or reschedule an exam before the end of the 60-day testing window and would like to request a new testing window, the candidate must complete both steps below: Check the Test Admission Notice for any errors and report them to DANB immediately at 1-800-367-3262. For example: • Exam type is incorrect • Candidate’s name is spelled incorrectly • The candidate’s ID reflects a different name (e.g., married, maiden, hyphenated, mother’s maiden name) STEP 1: Cancel the exam appointment: If an exam appointment has been scheduled, the candidate must cancel the appointment with Pearson VUE at least 24 hours before the scheduled exam start time. An exam appointment can be canceled online by visiting Pearson VUE’s website, www.vue.com/danb, or by calling Pearson VUE’s toll-free hot line during normal business hours. Failure to cancel an exam appointment will result in forfeiture of the full application/exam fees, and the application is null and void. The name on the Test Admission Notice must match the candidate’s ID exactly. The middle name does not need to be spelled out, but the initial must match (e.g., “M” on the ID and “Mary” on the Test Admission Notice is acceptable and vice versa). STEP 2: Request a new 60-day testing window: Mail or fax the Request a New Testing Window form to DANB within 60 days (pay $60 nonrefundable fee) after the end of the original testing window. A candidate may request a new testing window only one time. After the first request for a new testing window, a current exam application with any required documentation and full fees must be submitted. The candidate will be turned away from testing if the name on the ID does not match the Test Admission Notice exactly and would need to reapply with a new exam application and pay the full exam fee. The 60-Day Testing Window The candidate must take the exam within the 60-day window listed on the Test Admission Notice. 4 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene Drug and Law Exam Requesting a New Testing Window Due to a Missed Exam Appointment If the candidate arrives more than 15 minutes after an exam appointment start time, the candidate will be accommodated at the discretion of the test center administrator. If the administrator is unable to accommodate the candidate, or if the candidate does not take a scheduled exam because the candidate missed the appointment (for any reason except a valid emergency) or the candidate was denied entry, the candidate may reapply for the exam with a reduced fee using the Request a New Testing Window Due to a Missed Exam Appointment form within 60 days of the missed exam appointment (after 60 days, the candidate must reapply for the exam with a new application, any required documentation and the full fee). DANB will mail the form to eligible candidates. If another appointment is missed (for any reason except a valid emergency) or the exam is not taken within the new testing window, a current exam application with full fee must be submitted; a candidate may request a new testing window due to a missed exam appointment one time. Taking a DANB Exam What to Bring to the Test Center Candidates are required to bring one form of acceptable ID to the test center. To be accepted, the candidate’s ID must be: • Currently valid, non-expired • Government-issued • Photo-bearing • Signature-bearing • In roman characters • The same exact name as listed on the Test Admission Notice Test centers may use an electronic fingerprinting, palm vein and/or photographic security system for identification purposes only. Test centers may use a video/audio recording system to enhance exam security. The candidate must not bring any reference materials or notes into any test center area. A locker will be provided at the test center to store any personal items. The candidate will be provided with an erasable noteboard and marker to use during the exam. No visitors or unauthorized individuals will be permitted in any test center area or building during testing sessions. Requesting a New Testing Window Due to an Emergency If an exam appointment is missed due to a personal emergency, the candidate must submit a Request to Receive a New Testing Window Due to an Emergency form explaining the emergency, and include supporting documentation. The request must be submitted within 60 days of the scheduled exam date. Download the form at www.danb.org. Call 1-800-367-3262 with any questions about what constitutes an emergency and appropriate supporting documentation. Approved requests will receive a new 60-day testing window at no additional fee. Test Center Environment The candidate will receive a tutorial before the exam to help the candidate feel comfortable with the computerized format and how to navigate the exam. The tutorial is not a practice test. The candidate will be given 5 minutes to complete the tutorial, which will not count against the time to take the exam. There are no breaks during the exam. Candidates may be excused to visit the restroom, one at a time. Candidates are not allowed to leave the building during test time. During the absence, the exam time clock will continue to run. No additional time will be provided. Canceling an Exam If a candidate has submitted an application for an exam and wishes to cancel (not reschedule), the candidate forfeits full application/exam fees and the application is null and void. No refunds are given for canceled exams due to the fact that DANB’s nonrefundable application fee of $75 and cancellation fee of $40 are nearly equal to the Washington Dental Hygiene Law Exam fee of $135. Candidate Behavior Before, During and After an Exam Appointment The behavior of each candidate taking the exam will be monitored. Improper behavior is not acceptable before, during or after an exam appointment. DANB seeks to ensure a fair and equitable testing experience for all individuals and to ensure the security and reliability of the process. DANB’s Disciplinary Policy & Procedures form, which is available at www.danb.org, contains examples of improper behavior. When Pearson VUE Cancels an Exam Appointment In the event of weather or other emergency, Pearson VUE will attempt to notify candidates by phone of an exam appointment cancellation and will reschedule at no additional fee. 5 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene Drug and Law Exam Exam Security The exam is confidential. Any individual who removes or attempts to remove testing-related materials from the test center, or who attempts to memorize, distribute or otherwise misuse an exam, in whole or in part, in any form or by any means, verbal or written, electronic or mechanical, for any purpose, without the prior express written permission of DANB, will be subject to legal action. Any candidate or certificant who engages in improper behavior also will be subject to disciplinary action by DANB, which may include denial or revocation of certification or recertification. The test center administrator will notify DANB of anyone who talks during the exam, gives or receives assistance, or otherwise engages or appears to engage in dishonest or improper behavior before, during or after the exam. Those candidates may be required to cease taking the exam and leave the test center. remain confidential; clients have no expectation of privacy with respect to items sent or received. DANB may disclose communications as necessary to comply with legal processes. DANB responds to phone and email messages within two business days. Hand Scoring DANB will hand score an exam on request. The candidate must submit a Request for Hand Scoring of Exam Results form and a $75 hand scoring fee to DANB within 30 days after the official score date printed on the exam results received. Hand scoring results are completed within 30 days of a request. If the pass/fail status is reversed as a result of the hand scoring, the $75 fee will be refunded. Official Exam Results WSJ candidates will receive an official exam result upon leaving the test center. The official exam results received at the test center should be retained for the candidate’s records. Each week, DANB will submit official candidate results to the WSDOH on behalf of the candidate. The candidate will not be required to submit WSJ exam results to the WSDOH. After reviewing a reported incident, DANB will determine whether there is reason to believe that a candidate has engaged in cheating or other improper behavior, or has otherwise violated the security of the exam. DANB may, at its discretion, pursuant to the procedures set forth in DANB’s Disciplinary Policy & Procedures, take disciplinary actions, including but not limited to the following: • Order the candidate to retake the exam at a time and place to be determined by DANB Invalidate or refuse to release the exam results of the candidate • Deny the candidate’s current application for certification • Require the candidate to wait a specified period of time before reapplying to take the exam • Revoke the candidate’s eligibility to sit for future exams • Take a combination of any of the above actions or other action that DANB may deem appropriate. Release of Exam Results Exam pass/fail results will not be released to employers or any individuals other than the candidate, except on written request of the candidate. DANB releases exam results or certification verifications to some state regulatory agencies. Verification of Certificates and Certification DANB will verify DANB certification and DANB exam pass/ fail status and the effective date(s) of certification over the phone to anyone on request, since these items are matter of public record and may be disclosed. DANB will not verify passing status of state exams over the phone, but will verify if a candidate has earned a state certificate or license issued by DANB on behalf of a state board of dentistry. A Candidate/ Certificant Request for Credential Verification form is available at www.danb.org. Only a candidate/certificant or employer may request written verification. DANB offers verification on its website. See the Application Statements for more details. If a test center administrator allows a candidate to take an exam that the candidate is not registered for, those exam results will not be valid. After the Exam Name Changes To change the name on record, a candidate must submit a Name Change Request form and required documentation. The form is available at www.danb.org. Appealing a Decision To appeal a DANB decision regarding eligibility, administrative or exam content issues, a candidate may submit a Request for Reconsideration form and a $50 appeal fee to DANB’s Executive Director within 30 calendar days of the date on the DANB correspondence that prompts the candidate to appeal (e.g., date on the letter indicating the candidate’s application was incomplete, date on candidate’s exam results). A copy of the policy and form governing re- quests for reconsideration is available at www.danb.org or by contacting DANB at 1-800-367-3262. Address/Phone Changes To notify DANB of address or phone number changes, the candidate may log in to their account at www.danb.org to update the information or email danbmail@danb.org or call 1-800-367-3262. DANB Communications All communications sent to and from DANB are DANB’s property. DANB cannot guarantee that communications will 6 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene and Law Exam Application Statements Please read the following Application Statements carefully. These statements apply to all DANB state exams. Candidate’s signature on the application indicates understanding and agreement to be legally bound by these statements. 1. I hereby apply to the Dental Assisting National Board, Inc. (DANB) for examination and certification by DANB and issuance of my exam results to the Washington State Department of Health (WSDOH), in accordance with and subject to the procedures and regulations of DANB and the WSDOH. Under penalty of perjury, I declare that the information provided on my application is true. I have read and agree to the requirements and conditions set forth in the DANB application packet covering eligibility for and the administration of certification exams, the certification process, and DANB policies, including but not limited to the DANB Code of Professional Conduct. I agree to disqualification from the exam, to denial of certification, and to forfeiture and return to DANB of any certificate granted me by the WSDOH based on DANB exam results, in the event that any of the answers or statements made by me in this application are false, or in the event that I violate any DANB rules or regulations. I authorize DANB to make whatever inquiries and investigations it deems necessary to verify my credentials or professional standing. 2. I hereby release DANB, its directors, officers, examiners and agents from any and all liability arising out of or in connection with any action or omission by any of them in connection with this application, the certification process, any exam given by DANB, any scoring relating thereto, the failure to issue me a certificate, or any demand for forfeiture or return of such certificate, and I agree to indemnify DANB and said persons and hold them harmless from any lawsuit, complaint, claim, loss, damage, cost or expense, including attorneys’ fees, arising out of or in connection with said certification activities. I UNDERSTAND THAT THE DECISION AS TO WHETHER I QUALIFY FOR A NATIONAL CERTIFICATION OR CERTIFICATE OF KNOWLEDGEBASED COMPETENCE RESTS SOLELY AND EXCLUSIVELY WITH DANB AND THAT THE DECISION OF DANB IS FINAL. Notwithstanding the above, should I fi le suit against DANB, I agree that any such action shall be governed by and construed under the laws of the State of Illinois without regard to conflicts of law. I further agree that any such action shall be brought in the Circuit Court of Cook County in the State of Illinois, or the United States District Court for the Northern District of Illinois; I consent to the jurisdiction of such state and federal courts; and I agree that the venue of such courts is proper. I further agree that should I not prevail in any such action, DANB shall be entitled to all costs, including reasonable attorneys’ fees, incurred in connection with the litigation. 3. I understand that except as provided below, this application and any information or material received or generated by DANB in connection with this application or the exam process will be kept confidential and will not be released unless I have authorized such release or the release is required by law. I understand that DANB will verify receipt of any DANB exam application and the date received, on request. I further understand and agree that DANB may also provide verification to anyone by phone, by mail or on DANB’s website regarding whether I hold any DANB certifications, any DANB certificates of knowledge-based competence, and any state-specific certificates administered by DANB on behalf of a state regulatory body. Phone and mail verification will be provided to anyone upon request and will consist of oral or written confirmation of whether I hold any of the DANB-administered credentials listed above and the effective dates for each credential. Online verification through DANB’s website may consist of online display of my name, the DANB-administered credentials I hold and dates earned, current DANB certification status, and my city and state of residence. My full address will not be posted online by DANB. I further understand and agree that DANB may, from time to time, provide my name, address and phone number to third parties (including but not limited to official DANB affiliates, potential employers; dental conference sponsors; federal, national or state organizations; or legislative committees or task forces proposing or informing stakeholders of legislation). I further understand that this consent will remain in effect unless and until I submit a written request to have this information omitted from release. I understand that if I do not want DANB to display my city and state of residence as part of the online verification process, then I must submit a written request for omission of this information to the following address: DANB Communications Department, 444 N. Michigan Ave., Suite 900, Chicago, IL 60611. (I understand that my name, credentials held [issued by DANB as described above] and current DANB certification status will be displayed for everyone; opting out of display of information is only possible for an individual’s city and state.) 4. I understand that by providing my email address on the application form, I am consenting to receive email messages from DANB and its official affiliates related to their products and services or news affecting the dental assisting profession. I understand that DANB agrees not to provide my email address to any other third party without my consent, and that I can request removal from DANB’s email distribution list by following the directions contained in the Privacy Policy section of DANB’s Terms and Conditions of Use of DANB.org, located at www.danb.org. 5. I authorize DANB to release my exam results to state regulatory agencies. Individuals cannot opt out of DANB release of exam results to state regulatory agencies. I also authorize DANB to use information from my application and exam(s) for statistical analysis, providing that any personal identification is deleted. 6. I understand that I can be disqualified from taking or continuing to sit for an exam, from receiving exam results and from obtaining certification if DANB determines through proctor observation, statistical analysis or any other means that I was engaged in collaborative, disruptive or other unacceptable behavior during the administration of or following the exam. 7. I understand that the content of all DANB exams is proprietary and strictly confidential information. I hereby agree that I will not disclose, either directly or indirectly, any question or any part of any question from the exam to any person or entity. I understand that the unauthorized receipt, retention, possession, copying or disclosure of any DANB exam materials, including but not limited to the content of any exam question, before, during or after the exam may subject me to legal action. Such legal action may result in monetary damages and/or disciplinary action including rescinding exam results and denying or revoking certification. 8. I understand that for each application submitted, DANB will process the appropriate payment. If I fail to show up for an exam for which I have applied, and there is no documented DANB-accepted emergency, and I failed to comply with DANB cancellation policies, I am still obligated to pay the full exam fee. I further understand that taking the exam and then revoking payment constitutes the wrongful use of DANB products and services and I may be subjected to legal action. I am obligated to pay for the exam whether I pass or fail. I agree not to dispute the exam fee. Exam results will be rescinded if the exam fee is not paid in full. 7 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene and Law Exam 2018 WSJ Exam Application This application will be accepted through Dec. 31, 2018. 1. Candidate must sign, date and submit all required documentation and fees to DANB. Incomplete applications will be denied and a refund minus the $75 nonrefundable processing fee will be issued. 2. Mail or fax completed application and supporting documentation to DANB. Full payment is required at the time of application. WSJ 3935 Section A: Signature and Date (Please sign and date with a pen.) I hereby affirm that my answers to all questions are true and correct, I have met all eligibility requirements, and I will comply with all DANB policies and procedures. I further affirm that I have read and understood the Application Statements contained in this packet, and I intend to be legally bound by them. I understand that the application fee is not refundable under any circumstances. I hereby apply in accordance with the rules and regulations governing the exam; and I herewith enclose the fee. I hereby agree that prior or subsequent to examination, the WSDOH or DANB may investigate my eligibility and may refuse to issue the exam results and such refusal may not and shall not be questioned by me in any court of law or equity or other tribunal, nor shall I have any claim in the event of such refusal to a return of the fee accompanying the application. Signature Date Section B: Candidate Information (Please type or print with a pen.) Last Four SSN Date of Birth / / Name (must match current ID exactly): Last First Middle Name/Initial Prior Name (if applicable) Email Home Address City State Zip Phone Numbers: Office Home Cell Section C: Work Experience Information I work in a: general dental office specialty dental practice other (please specify) ____________________________ Section D: Payment (Please type or print with a pen.) Candidate’s Name WSJ 3935 Check/Money Order payable to DANB (must include candidate’s name and be in U.S. dollars) Credit Card Authorization (VISA, MasterCard, Discover & American Express accepted): Credit Card Number Amount $135.00 CVV Expiration M M Y Y Cardholder’s Name Cardholder’s Billing Address State Zip City Daytime Phone Number Cardholder’s Signature By signing, the cardholder acknowledges intent to register for the aforementioned DANB exam in the amount of the total shown hereon and agrees to perform the obligations set forth in the cardholder’s agreement with the issuer. Furthermore, the cardholder understands that the signature obtained at the exam administration shall be used to indicate receipt of purchase. A candidate who fails to show up for the exam for which he/she registered and has not canceled the exam as described in this packet is still required to pay for the exam. (See the Application Statements for further requirements.) Mail: DANB • 444 N. Michigan Ave., Suite 900 Chicago, Il 60611 Questions? 1-800-367-3262 or www.danb.org Fax: 1-312-642-8507 Do not submit twice or you will be charged twice 8 416.5 Washington State Dental Hygiene Drug and Law Exam Washington State Dental Hygiene and Law Exam Application Checklist Have you: Read the instructions and information in this application packet? Read and agreed to be bound by Washington and DANB rules, regulations, policies and procedures as noted in this application packet? (See Application Statements, p. 7) Filled out the exam application in its entirety? Signed and dated the exam application? Enclosed the application and exam fee or provided credit card information? Enclosed the Reasonable Accommodations Request forms, if needed? Note: These forms can be found at www.danb.org. Made a copy of your entire application packet for your records? Addressed your envelope OR prepared your information to be faxed? Mail to: Dental Assisting National Board, Inc. (DANB) 444 N. Michigan Ave., Suite 900 Chicago, IL 60611 Fax credit card payments only to: DANB 1-312-642-8507 If you have not: • completed the application in full, • enclosed, signed and dated your application, and • provided payment (check, money order, cashier’s check) or payment information (credit card) your application will be considered incomplete and will not be processed. Incomplete applications will be denied and a refund minus the $75 nonrefundable application fee will be issued. 9 416.5 Washington State Dental Hygiene Drug and Law Exam RCW/WAC and Online Website Links RCW/WAC Links Uniform Disciplinary Act, RCW 18.130 Administrative Procedure Act, RCW 34.05 Administrative Procedures and Requirements, WAC 246-12 Dental Hygienist Laws, RCW 18.29 Dental Hygienist Rules, WAC 246-815 Dentistry Laws, RCW 18.32 On-Line AIDS Training Resources Reference Page Dental Hygiene Examining Committee, Web page Continuing Education (CE) Dental Hygienists Continuing Education Rules, WAC 246-815-140 15 hours/annually of training RCW/WAC and Online Website Links March 2017
Source Exif Data:
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