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APPLICATION FOR ADMISSION

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EXPANDED FUNCTION DENTAL AUXILIARY PROGRAM Application Checklist APPLICATION FOR ADMISSION Official transcripts from your high school or college identified by seal of issuing institution Documentation
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EXPANDED FUNCTION DENTAL AUXILIARY PROGRAM Application Checklist APPLICATION FOR ADMISSION Official transcripts from your high school or college identified by seal of issuing institution Documentation of your current status as an auxiliary, i.e. notarized copy of your hygiene license or current CDA certificate, or a copy of your application to sit for the DANB OR CODA exam Letters of recommendation from two persons (other than your dentist-employer). Letter of verification for 2 years in general dentistry within past 5 years as a chairside assistant Hepatitis B vaccination documentation or proof of current titer if vaccine documentation cannot be provided Current TB test (PPD) documentation (yearly test) Copy of dental assisting school diploma (if applicable) Completed Employer Recommendation Form Completion of Program Performance Requirements Completion of Employer / Remote Site Sponsor Completion of Personal Statement *Foreign trained dentists: Education Course Evaluation Documentation Name: APPLICATION FOR ADMISSION Please complete application and return with your application fee of $40. Name (Last) (First) (Middle) (Maiden) Address (Street) (City) (State) (Zip) ( ) - ( ) - Residence Phone Cell Phone Address Social Security # Date of Birth Years in Dentistry Latex Allergy? Gender Are you a citizen of USA? Yes No If not, please list which country: Visa: Ethnicity Are you Hispanic or Latino? Yes No If you wish to be identified with a particular ethnic group, please check all that apply: African American, African, Black Native American, Alaska Native Asian American (country): Asian, incl. Indian Subcontinent (country): Hispanic, Latino (country): Mexican American, Chicano Puerto Rican Native Hawaiian, Pacific Islander White or Caucasian Other (specify): Training Where did you receive your dental assisting or hygiene training? Right or left handed (for seating purposes)? How many years in dentistry? Preferred class time: Wednesday Friday Flexible CDA RDH Foreign-trained Dentist (Day cannot be guaranteed due to space limitations) Employer Info Employer-dentist Address (Street) (City) (State) (Zip) ( ) - Business phone Educational Record School Check highest level completed High Name of School and Location Degree Year Graduated Vocational College/ University Other Page 2 of 8 Dental Employment Experience Name of Employer Mailing Address Date of Employment From mm/dd/yy To mm/dd/yy Please have the following sent to Case Western Reserve School of Dental Medicine: 1. Official transcripts from your high school or college identified by seal of issuing institution. 2. Documentation of your current status as an auxiliary, i.e. notarized copy of your hygiene license or current CDA certificate, or a copy of your application to sit for the DANB OR CODA exam. 3. Letters of recommendation from two persons (other than your dentist-employer). 4. Letter of verification for 2 years in general dentistry within past 5 years as a chairside assistant. 5. Hepatitis B vaccination documentation or proof of current titer if vaccine documentation cannot be provided 6. Current TB test (PPD) documentation 7. Copy of Dental Assisting school diploma (if applicable). 8. Completed Employer Recommendation Form 9. Completion of Employer / Remote Site Sponsor 10. Completion of personal statement 11. Foreign trained dentists: Education Course Evaluation documentation Prior to action on this application, all materials must be received by Case Western Reserve University School of Dental Medicine along with this form and a nonrefundable $40 application fee. *This fee is not applicable to tuition. Please be sure all correspondence has your complete address. Send to: Case Western Reserve University School of Dental Medicine EFDA Program Euclid Avenue Cleveland, OH *Please make check payable to: Case Western Reserve University-EFDA Program I HEREBY CERTIFY THAT THE STATEMENTS I HAVE MADE HEREIN ARE TRUE. ANY FALSE INFORMATION MAY LEAD TO DISMISSAL FROM THE PROGRAM. Signature (applicant MUST sign) Date Page 3 of 8 Personal Statement (attach additional page, if necessary) In the space below, please indicate: 1. Why you would like to become an EFDA? 2. Your knowledge of EFDA duties (in Ohio). 3. Your willingness and ability to spend the necessary time, outside class, to complete required reading and studying. 4. How you plan to use your EFDA training once you become certified. Page 4 of 8 Case Western Reserve University School of Dental Medicine Expanded Functions Dental Auxiliary Program Employer Recommendation Form The purpose of this form is assist the admissions committee in selecting students applying to the CWRU EFDA Program that show evidence of the skills necessary to become an EFDA in Ohio. This information is held in strict confidence and will be used solely for making decisions about annual admittance into the EFDA Program. Applicant s Name: Date: Length of employment with current employer dentist: The following evaluation should be based on demonstrated performance compared to that reasonably expected of an auxiliary at his or her level of training, experience and background. Please mark an X in the appropriate box listed for each item listed: PERFORMANCE POOR FAIR GOOD SUPERIOR Basic Professional Knowledge NOT OBSERVED Judgement Professional Manner and Appearance Technical / Hand Skills Following Direction Cooperativeness Punctuality / Dependability Communication Skills Current Dentist Employer Name (printed): Address: Dentist Signature: Phone: Page 5 of 8 Program Performance Requirements All students admitted to the Expanded Function Dental Auxiliary Program must be able to meet the following requirements: 1. Students must be familiar with restorative procedures 2. Students must be able to use both direct vision and indirect mirror vision to complete and evaluate restorations, and will have to perfect fine motor skills to enable the accurate and safe application of dental handpieces and instruments. 3. Students must be familiar with basic dental terms and nomenclature. 4. Students must be able to function effectively under the time constraints of the program and display flexibility in the event of changing lab and clinical. situations. 5. Students must be able to apply didactic learning (theory) to clinical situations. 6. Students must be able to hear and communicate effectively, follow directions and act professionally in class and when delivering patient care. 7. Students must be able to read the printed words in EFDA textbooks and supplemental information, observe various dental instrument angulations and apply the concepts appropriately. 8. Student s eyesight must be able to visualize fine detail (either naturally or corrected),have depth perception and have the ability to visualize three dimensional objects. 9. Students must be physically free of the use of non-prescription drugs, illegal drugs and alcohol. 10. Students must be able to read and speak fluent English. 11. Students must show acceptable progress and pre-clinical competency in the program by a prescribed time before they are allowed to provide care to patients. I acknowledge that I have read and understand the program performance requirements expected of me should I be accepted into the EFDA Program. Signature Date Page 6 of 8 Case Western Reserve University School of Dental Medicine Expanded Functions Dental Auxiliary Program Employer Remote Site Participant Form I understand that my auxiliary is applying to the CWRU EFDA Program and that if accepted, I will be expected to allow her / him to place restorations in office (amalgam, composite and pit and fissure sealants) on patients under my Direct Supervision during the second semester of the course in order to fulfill the Ohio State Dental Board required hours of patient clinical care to complete the program. I further understand that I will receive from my auxiliary(once enrolled) information to learn about the grading criteria, discuss sections of the Ohio Revised Code and be presented a document requiring my signature indicating my office be used as a remote site facility while my auxiliary is attending the EFDA Program. (Pint name Dentist) (Signature Dentist) (Date) Page 7 of 8 Clinical Site Requirement Information for the Dentist / EFDA Applicant The EFDA student will complete the basic typodont restorations that we require before permitting clinical experience in the first semester of the program. Then, in the second semester, authorization will be given for your auxiliary to begin placing Classes I, II, III, and V amalgam, Classes I, II, III, IV and V composite, and temporary restorations on selected patients under your direct supervision. Documentation of the completed restorations must be recorded in the students' grade sheets and must be evaluated immediately after placement using the grading key provided. In addition, the EFDA student may also place rubber dam (including clamp placement), pulp protection materials and pit and fissure sealants. The dentist s responsibilities include evaluation of restorations, documentation of completed restorations, and documentation of hours accrued. The Ohio State Dental Board mandates that EFDA students accrue clinical/patient experience placing restorations. 40 hours may be given in our remote facilities on class days and the other 40 to be acquired in private practice on non class days. Any additional hours will enhance the performance grade. The requested hours of hands-on experience in private practice is a requirement necessary to allow the auxiliary to sit for the EFDA board exam administered by the Commission on Dental Testing in Ohio. Page 8 of 8
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