Prelim. Application

 

 Dental Assisting Program

 CDAMP Preliminary Application

The purpose of this form is to assess an applicants status in the educational requirements to become a New York State licensed Registered Dental Assistant, and then to recommend an appropriate CDAMP educational program to reach this goal.

All students must have a dentist to act as a local preceptor.

BE SURE TO MAKE A COPY OF YOUR COMPLETED FORM.

If you do not receive a letter from CDAMP within one week, mail the form to Sheryl Robinson, 459 Philo Road, Elmira, NY 14903

or FAX to S. Robinson, CDAMP, 607-795-5309

Applicant's Information

Name
Address
 
City
State
Zip Code
Work Phone
Home Phone
FAX
E-mail (for us to contact you at)

Were You Ever Known to Any School, Employer, Agency, or Reference by Another name? Yes No

If Yes, Indicate What Name

Present Dental Assisting Status

Are You Certified By DANB (Dental Assisting National Board)?
Yes No

If Yes, What Year Did You Take the DANB Exam?

If No, Have You Passed Any Section of the DANB Exam and if so When?

General Chairside Assisting

Infection Control Exam (ICE)

Dental Radiography Exam

Have You Passed the New York State Dental Assisting Exam?
Yes No

Have You Applied to NY State For Licensure as a NYS Licensed Registered Dental Assistant?
Yes No

If yes, What was Their Response and/or What Areas Where You Determined to Be Deficient In?

Is your CPR Certification Current?
Yes No

If Yes, Date of Last Course/Renewal.

Do You Have a Dentist Who is Willing to Function as Your Primary Preceptor? Yes No

Dentist Name

Type of Dental Practice / Specialty

Address Line 1 

Address Line 2

City & State
Zip Code

Telephone

Fax

Dentist E-mail

Which Tier Level Do You Think You Presently Qualify For? (As Described in the CDAMP Syllabus Overview.)

Tier I Tier II Tier III Tier IV

Educational Information

Highest Level of Completed Education:

GED High School Diploma Some College Associate  Degree
Bachelor Degree Some Post Graduate Masters Degree Doctorate Degree

Name and Location (City) of High School, & Graduation Date

Colleges Attended and Major and Degree or Credits Hours Earned

College/University Attended Major/Focus Credit Hours

1.

2.

3.

Formal Dental Education Programs Attended (Assisting/Hygiene/Etc.) Courses/Hours/Years Completed

Continuing Dental Education Courses Attended

(Information May Be Cut and pasted from another Text Document.)

Dental / Medical Related Work Experience:

Approximately How Many Total Hours or Years of Dental Work Experience Do You Have?

(There are Approximately 1750 Hours per Work Year)

Present or Most Recent Dental Practice Information

Doctor/Office Name

Type of Dental Practice / Specialty

Address Line 1 

Address Line 2

City & State

Zip Code

Telephone

Fax

Office E-mail

Position Held

Hours/Years Worked (There are Approximately 1750Hrs/Yr.)

Previous Dental Practice Information

Doctor/Office Name

Type of Dental Practice / Specialty

Address Line 1 

Address Line 2

City & State

Zip Code

Telephone Fax

Office E-mail

Position Held

Hours/Years Worked (There are Approximately 1750Hrs/Yr.)

Additional Dental Practice(s) Employment Information (Include Dentist/Practice Name, Practice Type, Hours/Years Employed & Position)

List Professional Licenses and Associations

By submitting this form, I certify that answers given herein are true and complete to the best of my knowledge.

Please print a copy of this application for your records.

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