Dental Hygiene License Application Packet 645 088 645135
User Manual: 645-088
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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 Verication ......................................................................... 1 page
8. 645-115 .....Out-of-State Credential Verication 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 Identication 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 Send other documents not sent
or money order payable to: with initial application to:
Department of Health Dental Hygiene Credentialing
P.O. Box 1099 P.O. Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
DOH 645-135 March 2017
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DOH 645-146 March 2017 Page 1 of 4
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 inltration: 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 ngerprint-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.
FApplication Fee. This fee is non-refundable. You can check the online fee page for
current fees.
FCheck if either apply:
Request for Military Training and Experience Evaluation
Spouse or Registered Domestic Partner of Military Personnel
F1. 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.
Application Instructions Checklist
DOH 645-145 March 2017 Page 2 of 4
National Provider Identier Number (NPI): The National Provider Identier (NPI)
is a standard unique identier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last.
Denition of legal name: “Legal name” is the name appearing on your ofcial
certicate of birth or, if your name has changed since birth, on an ofcial marriage
certicate 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 notied
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.
F2. Personal Data Questions:
All applicants must answer the same personal data questions. They are focused on
your tness 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 trafc 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 certicate(s) of restoration of opportunity, please
provide a certied copy of each certicate.
• Another jurisdiction means any other country, state, federal territory, or military
authority.
F3. Education:
List in date order, most recent to later, all of your educational preparation and post-
graduate 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 ofcial school transcripts directly to
the Department of Health.
F4. 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.
F5. 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.
F6. Other License, Certication, 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 verication form is provided in this packet.
F7. AIDS Education and Training Attestation:
Read the AIDS education and training attestation. AIDS training may include self-
study, 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.
F8. 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 certicate 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 Certicate 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 EBenets website.
- You can request a replacement copy of your NGB-22 on the
National Archives website.
• Ofcial 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.
• Verication 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
DOH 645-137 March 2017 Page 1 of 2
Thank you for applying to become a licensed dental hygienist in Washington State. To
expedite the license process, please use the following checklist.
FVerication 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 certication 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
Verication 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.
Verication(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 2 of 2
FOut-of-State Credential Verication
A verication/certication 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:
FPay the credentialing application fee.
FYou 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.
FYou 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 deciencies.
• 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.
City State Country
Place of birth
DOH 645-090 March 2017 Page 1 of 5
Revenue: 0251040000
Date
Stamp
Here
Name First Middle Last
Note: The mailing and email addresses you provide will be your addresses of record. It is your responsibility to
maintain current contact information on le with the department.
Country
Will documents be received in another name? F Yes F No
If yes, list name(s):
Address
City State Zip Code County
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address:
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Country
Mailing address if different from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
1. Demographic Information
Dental Hygiene Application
Select One:F License by examination F License by endorsement of credentials and examination
Dental Hygiene School Year graduated
Approved dental hygiene expanded functions program? F Yes F No Date approved
Social Security Number (SSN)
(If you do not have a SSN, see instructions) F Male
F Female
National Provider Identier Number (NPI)
(Enter 10 digit number)
Select if either apply: F Request for Military Training and Experience Evaluation
F Spouse or Registered Domestic Partner of Military Personnel
DOH 645-090 March 2017 Page 2 of 5
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. .......................................FF
“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, specic 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 eld 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 condentiality 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. ...................................FF
“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? ............................................................................................................................................... FF
4. Are you currently engaged in the illegal use of controlled substances? ...................................................FF
“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
certied 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? ...FF
Note: If you answered “yes” to question 5, you must send certied 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 certicate(s) of restoration of opportunity, please provide
a certied copy of each certicate.
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.
2. Personal Data Questions Yes No
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
(mm/yyyy)
End
(mm/yyyy)
DOH 645-090 March 2017 Page 3 of 5
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? ................................................... FF
b. Diverted controlled substances or legend drugs? ................................................................................FF
c. Violated any drug law? .........................................................................................................................FF
d. Prescribed controlled substances for yourself? ....................................................................................FF
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? .................................................................FF
8. Have you ever had any license, certicate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ..............FF
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? ...............................................................................FF
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? .........................FF
11. Have you ever been disqualied from working with vulnerable persons by the Department
of Social and Health Services (DSHS)? ...................................................................................................FF
2. Personal Data Questions (cont.) Yes No
DOH 645-090 March 2017 Page 4 of 5
4. Examination
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.
Name of Business Total Number of
Months
Dates
Start
mm/yyyy
End
mm/yyyy
6. Other License, Certication, or Registration
List all states where credentials are or were held. Attach additional completed pages if you need more space.
State/
Jurisdiction
Currently in
force
Certicate
Year issued Number
F No F Yes
F No F Yes
F No F Yes
F No F Yes
F No F Yes
Permanent or
Temporary
Profession
The examinations listed below are the approved examinations for licensure. Check all that you have taken.
FDental Hygiene National Board examination. Date of exam: ___________________________
FWashington State Drug and Law exam (administered by Dental Assisting National Board, Inc.).
Date of exam: ___________________________
FWREB Patient Evaluation/Prophylaxis. Date of exam: ___________________________
FWREB Anesthesia examination. Date of exam: ___________________________
FWREB Restorative examination. Date of exam: ___________________________
FCRDTS Restorative examination if passed after March 7, 2016.
Date of exam: ___________________________
FCRDTS Patient Evaluation/Prophylaxis. Date of exam: ___________________________
FCDCA (NERB) Patient Evaluation/Prophylaxis. Date of exam: ___________________________
Please note: The CDCA (NERB) is only accepted for the time period of January 1, 2000 to August 21, 2009.
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
DOH 645-090 March 2017 Page 5 of 5
7. AIDS Education and Training Attestation
Applicant’s Initials Date
8. Applicant’s Attestation
I, ________________________________________ , declare under penalty of perjury under the laws of
the state of Washington the following is true and correct:
• I am the person described and identied 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 les 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 _______________________________________________
By: _______________________________________________________________________________
(Signature of applicant)
(Print applicant name clearly)
(mm/dd/yyyy)
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 condentiality, 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.
(City, state)
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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 Contact Phone—253-964-6248
Fort Steilacoom Contact email—vm-dentalinstitute@pierce.ctc.edu
Lakewood, WA www.pierce.ctc.edu
Summer Course (August—Anesthetic, Nitrous Oxide and Restorative)
Lake Washington Contact the Dental Hygiene Department: Beth Davis at 425-739-8386
Institute of or Monta Frost, Director at 425-739-8404
Technology Winter (Anesthetic and Nitrous Oxide)
Kirkland, WA Summer (Anesthetic and Nitrous Oxide)
Eastern Washington Contact Phone—509-828-1300
University Contact email—awetmore@ewu.edu
Cheney, WA www.ewu.edu
(Restorative)
Phoenix College Contact Nan Reif, Director, Center for Health Professions 602-285-7331
Phoenix, AZ Classes available in May and in the Fall (Anesthetic and Nitrous Oxide)
Oregon Health & Contact Debbie Reaume, Continuing Education Program 503-494-8857
Science University Contact school for class date and times (Nitrous Oxide)
Portland, OR
Portland Community Contact Bem Hanamoto, 971-722-6627
College Contact email—bem.hanamoto@pcc.edu
Institute for Health www.pcc.edu/climb/health
Professionals (Restorative)
Portland, OR
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
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DOH 645-089 March 2017
The student listed above has graduated or successfully demonstrated the following at
____________________________________________________ on ________________________________
which is a dental hygiene program accredited or approved by the following:
FExpanded functions education program approved by the Secretary of the Department of Health.
FThe American Dental Association Commission on Dental Accreditation for dental hygiene.
FTheCommission on Dental Accreditation of Canada (CDAC) for dental hygiene.
Name of program
Signature of Program Director
Program Director Name (Please print)
F F a. Didactic and clinical competency in the administration of injections of local anesthetic, which includes
inltration: ASA, MSA, Nasopalatine, greater palatine. Block: Long buccal, mental, inferior alveolar, and
PSA;
F F b. Didactic and clinical competency in the administration of nitrous oxide analgesia;
F F c. Didactic and clinical competency in the placement of restorations into cavities prepared by a dentist;
and
F F d. Didactic and clinical competency in the carving, contouring, and adjusting contacts and occlusions of
restorations.
Yes No
Dental Hygiene Credentialing
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
School Seal
Dental Hygiene Education Verication
Note: this form must be submitted directly from the Dental Hygiene program.
Date
Name First Middle Last
Date of Birth
City
Address
Applicant Information:
State Zip Code
Please check the answers applicable to this student. Please note clinical competency means on live patients.
To be completed by the dental hygiene program:
(mm/dd/yyyy)
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DOH 645-115 March 2017 Page 1 of 3
Dental Hygiene Credentialing
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
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, certied, or registered as a healthcare provider.
The regulatory agency will complete pages two and three.
Out-of-State Credential Verication
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.
Washington State healthcare credential number (if available) Date Issued
Name: Last First Middle
Mailing Address
Any other names used
City State Zip Code
Washington State healthcare credential type you are applying for
Phone (enter 10 digit #) Cell (enter 10 digit #)
Email address
Type of license(s) you hold or have held in other state(s), jurisdiction(s) or Canadian provinces
Please complete this form regarding the applicant listed on the reverse. Submit the completed
form and any other requested material directly to this ofce at the address on the reverse. We
will not accept the form if submitted by the applicant. Thank you.
Name of license, certication, or registration holder:
Authority providing verication: (state, jurisdiction or Canadian province, name, and title)
Applicant was credentialed by:
FWritten Examination
Name of examination:
FOther Examination Date: Score:
Name of examination:
Is credential current:
F Yes F No Expiration Date:
Is this individual considered to be in good standing in your state or Canadian province?
Has this credential ever been denied? F Yes F No
Suspended? F Yes F No
Revoked? F Yes F No
Surrendered? F Yes F No
Reinstated? F Yes F No
If “yes,” please provide a copy of the nal 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? F Yes F No
Signature:
Title:
Date:
(To be Completed by the Regulatory Agency)
F Yes F No If “no,” please attach explanation.
Date: Score:
DOH 645-115 March 2017 Page 2 of 3
Ofcial Seal
Authority Providing Verication ________________________________
Name ____________________________________________________
Signature _________________________________________________
Title ______________________________________________________
Date _____________________________________________________
The state, jurisdiction, or Canadian province of ______________________________________
allows the following scope of dental hygiene practice:
Yes No
____ ____ (a) Oral inspection and measuring of periodontal pockets;
____ ____ (b) Patient education in oral hygiene;
____ ____ (c) Taking intra-oral and extra-oral radiographs;
____ ____ (d) Applying topical preventive or prophylactic agents;
____ ____ (e) Polishing and smoothing restorations;
____ ____ (f) Oral prophylaxis and removal of deposits from the surface of the teeth;
____ ____ (g) Recording health histories;
____ ____ (h) Taking and recording blood pressure and vital signs;
____ ____ (i) Performing subgingival and supragingival scaling; and
____ ____ (j) Performing root planing.
I further certify this information is true and correct to the best of our knowledge.
State, jurisdiction or Canadian province
Ofcial State or
Canadian Province
Seal
DOH 645-115 March 2017 Page 3 of 3
This Form May Be Duplicated
(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.
(This page intentionally left blank.)
Qualifying Examinations for
License for Dental Hygienists in Washington State
Region State ...................... Qualies 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
Maine ..................... Patient Evaluation / Prophylaxis
Maryland ................ Patient Evaluation / Prophylaxis
Massachusetts ...... Patient Evaluation / Prophylaxis
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 ...................... Qualies 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
Only accepted for
the time period of
January 1, 2000 to
August 21, 2009
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
2 416.5 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 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.
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.
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
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
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.
Washington State Dental Hygiene Drug and Law Exam
3 416.5 Washington State Dental Hygiene Drug and Law Exam
Applying for an Exam
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.
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.
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.
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.
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
• Expired exam application
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.
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.
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.
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.
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.
Washington State Dental Hygiene Drug and Law Exam
4 416.5 Washington State Dental Hygiene Drug and Law Exam
Retaking a Passed Exam
DANB certificants/candidates may take and pass DANB-
administered 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.
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.
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.
Scheduling a DANB Exam
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.
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)
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).
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.
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.
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.
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.
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.
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:
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.
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.
Washington State Dental Hygiene Drug and Law Exam
5 416.5 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.
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.
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.
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.
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.
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.
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.
Washington State Dental Hygiene Drug and Law Exam
6 416.5 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.
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.
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.
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
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.
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.
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.
Washington State Dental Hygiene and Law Exam
7 416.5 Washington State Dental Hygiene Drug 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 KNOWLEDGE-
BASED 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.
Washington State Dental Hygiene and Law Exam
8 416.5 Washington State Dental Hygiene Drug 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.
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
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): Amount $135.00
Credit Card Number CVV Expiration
Cardholder’s Name
Cardholder’s Billing Address City
State Zip 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 Fax: 1-312-642-8507
Questions? 1-800-367-3262 or www.danb.org Do not submit twice or you will be charged twice
M
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WSJ
3935
WSJ
3935
Washington State Dental Hygiene and Law Exam
9 416.5 Washington State Dental Hygiene Drug 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.
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
