Guide Sheet for Application for Dental Assistant Registration

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1 Guide Sheet for Application for Dental Assistant Registration General Complete all fields of the application in full. Enter N/A for information that does not apply to you. Submit the completed original application with appropriate fees and documentation by mail, courier or hand delivery to the address above. Faxed or ed applications will NOT be accepted. Allow the College 5 to 10 business days to process your application once ALL requirements are met and verification has been received by the College. Section 1: Personal Information Information you provide to the College is protected as per the College s Privacy Policy (see end of this Guide Sheet). Attach a copy of Canadian government issued identification which states your legal name and date of birth. (e.g. driver s license, passport, resident card, citizenship card) If your current legal name is different than the name on your verification documents you must also attach a copy of legal documents certifying your name change. (e.g. marriage certificate, legal name change) In the First, Middle and Last Name areas, provide your legal name as it appears on your identification. If you go by a name other than your legal name, provide that name as your Preferred Name. Your maiden name is your surname as it appears on your birth certificate. For the Name Tag it is recommended that you use your first name, or preferred name, only. New registrants are issued an RDA name tag. Provisional registrants will be issued an RDA name tag when their status is transferred to Registered. If your current personal contact information will be changing before the College can issue your registration documents, please provide a reliable care of address and phone number where you can receive important information, documents or messages. Promptly inform the College of all changes to your information. You must provide a personal address as the College uses as its primary communication method. An address is also required to access the Members Area of the website. Section 2 and 3: Registration Options Complete Section 2 OR Section 3. College of Alberta Dental Assistants Ave NW Edmonton AB T5L 4S This Guide Sheet contains important information. Please read it carefully before completing the Application for Dental Assistant Registration. Section 2: Applying Pursuant to a Labour Mobility Agreement Applying pursuant to one of the Canadian labour mobility agreements (MRA, TILMA, AIT, New West Partnership) is for applicants who hold current practice rights in another regulated Canadian jurisdiction. At this time Ontario and Quebec applicants do not qualify to apply via labour mobility as the profession of dental assisting is not regulated in those jurisdictions. If you have more than one instance of current practice rights in another regulated jurisdiction, record details on the reverse of the page or attach a separate sheet. For each instance of current practice rights in another regulated jurisdiction you will need to submit a Verification of Registration/License/Certification (R/L/C) form (attached, copy as needed) to the respective regulatory authority. The College considers Verification of R/L/C forms valid for 30 days after the date they are completed by the regulatory authority. Applicants who are approved for Alberta registration will be granted a practice permit and authorization to perform the intra-oral skills for which an Alberta equivalent to the originating jurisdiction exists. S:\Public\Registration\Application\Guide Sheet.docx College of Alberta Dental Assistants December 2015 The College of Alberta Dental Assistants regulates its members in the public interest, promoting the delivery of safe, quality oral health care.

2 Section 2 and 3: Registration Options continued Section 3: Applying with the National Dental Assisting Examining Board (NDAEB) Certificate Applying with the National Dental Assisting Examining Board (NDAEB) Certificate is for new graduates, applicants from Ontario and Quebec, internationally educated applicants, and those who do not meet the registration requirements for applying through labour mobility. Attach a copy of documents to verify NDAEB certificate. Applicants who have graduated from a dental assisting program that is not accredited by the Commission on Dental Accreditation of Canada (CDAC) must demonstrate successful completion of the NDAEB written examination and Clinical Practice Evaluation (CPE) within three years of application or successful completion of intra-oral upgrading at a CDAC-accredited dental assisting program. If you have completed multiple NDAEB CPE attempts, please provide the date of the most recent attempt. Attach a copy of documents to verify NDAEB written examination and CPE, or completion of Intra-Oral upgrading. Applicants must apply for registration via the NDAEB Certificate within three years of education completion date, or must have completed an in-school clinical refresher at a CDAC-accredited dental assisting program within three years of application, or applicants must demonstrate employment as a dental assistant performing intra-oral duties for at least 900 hours within the three years preceding the date of application. Attach a copy of documents to verify education completion date or clinical refresher course or employment. If demonstrating employment you must attach a letter from your employer. Employment letters must include: employer name and contact information; length of employment; approximate number of hours worked; and type of services provided. If you have more than one instance, record details on the reverse of the page or attach a separate sheet. Provisional Registration Applicants that have not yet met all of the requirements for full registration may be eligible for Provisional Registration. When applying for registration, the applicant must demonstrate one of the following: Successful graduation from a Commission on Dental Accreditation of Canada (CDAC)-accredited dental assisting program and eligibility to take the NDAEB written examination. Complete Section 3 and attach a copy of documents to verify completion of dental education programs and scheduled NDAEB written examination date. Successful completion of dental assisting or related dental education and successful completion of the NDAEB written examination and completion of an initial NDAEB CPE successful in at least one skill. Complete Section 3 and attach a copy of documents to verify completion of dental education programs, NDAEB written examination and CPE. Current student in a CDAC-accredited dental assisting distance delivery program and successful completion of at least one intra-oral education program. Complete Section 4 and attach a copy of documents to verify current student status and completion of intra-oral education. All new Provisional registrants Provisional Practice Permits expire on November 30; Provisional status may be renewed if necessary up to a maximum of one year (365 days) total. Provisional registrants will be transferred to full registration status upon completion of their final registration requirements, at no additional fee. A person who is registered on the provisional register may practice only while supervised by a dental assistant registered on the general register or by a dentist, dental hygienist, denturist or other person approved by the Registrar. Supervision means on-site and able to assist. Section 4: Dental Education Attach a copy of documents to verify completion of dental education programs. If your dental education was obtained outside of Canada, also provide a copy of your qualification assessment. (i.e. IQAS or WES report) Attach a copy of documents to verify completion of Intra-Oral upgrading if applicable. If you have more than one instance of education, record details on the reverse of the page or attach a separate sheet. S:\Public\Registration\Application\Guide Sheet.docx College of Alberta Dental Assistants December 2015

3 Section 5: Professional Information If you have previously held dental assisting practice rights in another regulated jurisdiction, record each instance. Use the reverse of the page or attach a separate sheet as necessary. For each instance of previous practice rights in another regulated jurisdiction you will need to submit a Verification of Registration/License/Certification (R/L/C) form (attached, copy as needed) to the respective regulatory authority. The College considers Verification of R/L/C forms valid for 30 days after the date they are completed by the regulatory authority. If you currently hold or you have previously held practice rights in any other regulated health profession you will need to submit a Verification of R/L/C form (attached, copy as needed) to the respective regulatory authority. The College considers Verification of R/L/C forms valid for 30 days after the date they are completed by the regulatory authority. If you have more than one instance, record details on the reverse of the page or attach a separate sheet and submit a Verification of R/L/C form for each instance. Section 6: Current Dental Employment Information Provide your current dental employment information. If you do not have a current dental employer, check unemployed or employed non-dental accordingly. If you have more than one dental employer, record details on the reverse of the page or attach a separate sheet. Section 7: Applicant s Statement A signature means that you agree to the Applicant s Statement. Section 8: Terms and Conditions A signature means that you accept the Terms and Conditions. Section 9: Applicant s Checklist Use the checklist to assist you in submitting all applicable supporting documents. Section 10: Fee and Payment Information Fees All applicants for registration are required to pay the application Assessment Fee plus GST ($ $5.00) and the Registration Fee ($254.00). The registration cycle begins December 1 and ends on November 30 of the following year. The Registration Fee is prorated mid-way through the registration cycle. Full Fee When applying for registration that begins between December 1 and May 31 applicants must pay the $ Assessment Fee plus $ Registration Fee. The registration will be in effect until November 30 immediately following the date of registration. Prorated Fee When applying for registration that begins between June 1 and November 30 applicants must pay the $ Assessment Fee plus $ (prorated) Registration Fee. The registration will be in effect until November 30 of the same year. Individual malpractice liability insurance is mandatory for dental assistants in Alberta. The registration fee includes malpractice liability insurance coverage. Payment Fees are to be made payable to the College of Alberta Dental Assistants. The official receipt of payment will only be issued in the name of the payer. The Assessment Fee is non-refundable. The Registration Fee is non-refundable once registration is granted. Privacy and Protection of Personal Information The College of Alberta Dental Assistants collects, uses and discloses personal information for the purpose of regulating dental assisting, as defined in the Health Professions Act (HPA). The information collected includes names, contact information, education information, payment information, as well as employment history and competence records. The information collected and disclosed may not apply to all membership categories. As a regulatory body, the applicable privacy legislation to the College is the Personal Information Protection Act (PIPA). The purpose of PIPA is to recognize the right of the individual to have his or her personal information protected. The College protects personal information by: paper files are stored in locked cabinets, electronic S:\Public\Registration\Application\Guide Sheet.docx College of Alberta Dental Assistants December 2015

4 records are maintained in an online system which is protected by authentication processes, employees and volunteers are required to sign confidentiality agreements. Personal Information Collection Identification Data is used to identify members, and for workplace demographics full name, maiden or other names, date of birth and gender (Government-issued identification is used to verify identity) Regulatory Data is used to determine status, restrictions, credentials, and conditions date of initial registration the member s unique registration number (RDA#) whether the member s registration is restricted to a period of time (usually Dec 1 to Nov 30) any conditions imposed on the member s practice permit (e.g. provisional) the status of the practice permit (e.g. registered, suspended or cancelled) membership status (leave of absence, student or courtesy) school of training, graduation date, supporting documentation (education credentials) practice specializations (ortho, scaling) restricted activity authorizations (skills) qualifications documentation (NDAEB certification, education, etc.) relevant information from a disciplinary order or criminal record whether the member is registered as a dental assistant in another jurisdiction (e.g. verification of registration) competence documentation (learning plans, verification of learning, practice hours collected for a specific purpose, and then destroyed) professional conduct information (investigation/disciplinary) verification of malpractice insurance coverage Contact Data is used to contact members home address, home phone, mobile phone and Employer Data is used to inform employers of cancelled/suspended status, competence program verification, and to contact members employment status, employer name, start and end dates, hours per week, work telephone, and Awards Data is used for historical information for award purposes positions held within the organization professional awards or honours Other data collected through communications with members correspondence, consent forms, user IDs/passwords and payment information Mandatory Personal Information Disclosure Information disclosed upon general enquiry a regulated member s full name and registration number Practice Permit status (registered, provisional, cancelled or suspended) registration period and any conditions /restrictions on the practice permit authorized practice, authorization to provide restricted activities/specializations (skills) disciplinary action (information released according to and within legislative limitations) Information disclosed to legislative and regulatory organizations Alberta Provider Directory, provided for workplace demographics, initiatives and planning for anyone who is or was a regulated member RDA#, status (reason for changing to non-regulated status), name, gender, date of birth, registration credentials, personal contact information, school of training and graduation date, dates of registration Regulatory - Verification of Registration/Letters of Standing/Certificate of Professional Conduct RDA#, name, registration status history, authorized practice (skills), disciplinary proceedings (if applicable), continuing competence audit status, reason for cancellation/suspension Malpractice Insurance Company Regulated members name, RDA# and mailing address will be provided to the insurance company, for the purposes of the provision of malpractice insurance coverage. More details on the College s PIPA compliance are available on the College website at > About CADA > Legislation and Regulatory Information > Privacy. Should you have any questions or concerns regarding these policies, contact the College Privacy Officer at the College office. If you have questions on matters not covered by this information, contact the College at or S:\Public\Registration\Application\Guide Sheet.docx College of Alberta Dental Assistants December 2015

5 College of Alberta Dental Assistants Ave NW Edmonton AB T5L 4S Application for Dental Assistant Registration The accompanying Guide Sheet contains important information and instructions for each section in the application. Please refer to the Guide Sheet as you complete the application. PRINT CLEARLY. Section 1: Personal Information Date of Birth (MM/DD/YYYY): Gender: Female Male OFFICE USE ONLY Registration # First Name: Middle Name: Last Name: Preferred Name: Maiden Name: Name Tag: Address: City/Province/Country: Postal Code: Primary Phone: Alternate Phone: Section 2: Applying Pursuant to a Labour Mobility Agreement In which jurisdiction do you hold current practice rights? Province Specify dates From (MM/DD/YYYY) Continue to Section 4 To (MM/DD/YYYY) Received: Identification Education NDAEB Written Results CPE Results Certificate Verification of Reg/License/Cert Employment Letter Refresher Letter Registration Approved: Registered Provisional Via: Labour Mobility NDAEB Education: Substantial Equivalence Accredited Non-accredited Registration Date: Reg. Term Full Prorated Payment MMS Simply Package Permit Provisional CRV full pkg Sent Date: Section 3: Applying with the National Dental Assisting Examining Board (NDAEB) Certificate How did you obtain the NDAEB Certificate? Transfer of Credentials Examination Clinical Practice Evaluation (CPE) Date of NDAEB written examination (MM/DD/YYYY): Not applicable Date of NDAEB CPE (MM/DD/YYYY): Not applicable Are you applying within 3 years of your education completion date? Yes continue to Section 4 No continue to next question Have you completed an in-school clinical refresher at a CDAC-accredited dental assisting program within 3 years preceding submission of this application? Yes specify date below, must provide verification, continue to Section 4 No continue to next question School Name Completion Date (MM/DD/YYYY) S:\Public\Registration\Application\Application for Dental Assistant Registration.docx College of Alberta Dental Assistants December 2015 The College of Alberta Dental Assistants regulates its members in the public interest, promoting the delivery of safe, quality oral health care.

6 Can you demonstrate employment as a dental assistant performing intra-oral duties for at least 900 hours within 3 years preceding submission of this application? Yes specify dates below, must provide verification No must complete clinical refresher (or NDAEB CPE within 3 preceding years provide CPE date above) to be eligible to apply Province From (MM/DD/YYYY) To (MM/DD/YYYY) Continue to Section 4 Section 4: Dental Education School Name: Location of School (city/province/country): Date of Education Completion (MM/DD/YYYY): Have you completed Intra-Oral upgrading through a dental assistant program or dental-related program which is accredited by the Commission on Dental Accreditation of Canada since your Education Completion date? Yes specify below, must provide verification No School Name Completion Date (MM/DD/YYYY) Section 5: Professional Information Have you held previous practice rights as a dental assistant in another regulated jurisdiction?... Yes specify below No Province From (MM/DD/YYYY) To (MM/DD/YYYY) Do you hold current or previous practice rights in any other regulated health profession?... Yes specify below No Organization From (MM/DD/YYYY) To (MM/DD/YYYY) Have you been disciplined, or are you currently being investigated by any professional regulatory body?... Yes - attach explanation Have you ever pleaded guilty or been found guilty of a criminal offence in Canada or an offence of a similar nature in a jurisdiction outside Canada for which you have not been pardoned?... Yes - attach explanation Do you have any physical or mental condition(s) or disorder(s) that may compromise your ability to provide safe, competent and ethical care?... Yes - attach explanation No No No Section 6: Current Dental Employment Information I am currently unemployed. Unemployed since (provide date): I am currently employed in a non-dental field. Employed non-dental since (provide date): I am currently employed in the dental field (must complete remainder of this Section, please list all current dental employers, if more space is needed, provide information on reverse or separate sheet) Employer Name: Start Date of Employment (MM/DD/YYYY): Job Description: Average hours worked per week: Work Work Phone: Employer City: S:\Public\Registration\Application\Application for Dental Assistant Registration.docx College of Alberta Dental Assistants December 2015

7 Section 7: Applicant s Statement I (print name) hereby provide consent to the College of Alberta Dental Assistants to collect, use and disclose personal information as required for reasonable matters including fulfillment of statutory requirements. Refer to the Guide Sheet or the College website for more information about privacy and disclosure. I certify that the information given and made part of this application is true and correct in every aspect and when I meet all the requirements for Alberta Registration I will: assume responsibility for meeting annual renewal requirements (payment of fees and completion of Continuing Competence Program requirements) by the renewal deadline of October 31 notify the College of name, address and employment information changes while employed within the province of Alberta, practice in accordance with the Health Professions Act and the Dental Assistants Profession Regulation adhere to the dental assistants Standards of Practice and Code of Ethics and perform only those duties and Restricted Activities in which I am competent after proper education, training and experience I fully understand my responsibilities and that failure to comply with any or all of the above may result in cancellation or suspension of my Practice Permit, pursuant to section 119(b) of the Health Professions Act, the College will release my name and RDA number to my employer. Signed Applicant s Signature Date (MM/DD/YYYY) Section 8: Terms and Conditions Before submitting your application and fees, please carefully review the following Terms and Conditions: When your application is received by the College your Assessment Fee will be processed and is non-refundable. Your application will be assessed by the College. You will be notified by of the result of the assessment. If the College s assessment identifies that your application meets the eligibility requirements, your Registration Fee will be processed and is non-refundable. Your registration will be completed by the College. If the College s assessment identifies that your application is incomplete and/or that you do not meet the eligibility requirements, your application and Registration Fee will be held by the College for up to 45 days. You will be required to complete the application requirements that the College assesses as outstanding and submit appropriate documentation within 45 days. If you do not fulfil all of the outstanding requirements, including fulfillment of the applicable Registration Fee, within that 45 day timeframe your application will expire and you will forfeit the $ Assessment Fee. To be clear, in that situation the Assessment Fee will not be returned to you. If your application expires and you begin a new application process in the future, payment of the Assessment Fee will be required. Your Registration Fee will not be processed if your application expires (in the case of a money order it will be returned to you). Your application and all submitted documentation will not be returned. All application requirements which are subject to time limitations (including but not limited to: verification of registration/license/certification, current dental assisting registration certification in another jurisdiction, graduation within three years of application, NDAEB CPE, refresher and dental assisting employment) must qualify as current at the time your application is approved by the College. Previously fulfilled requirements which expire prior to fulfillment of outstanding requirements will become invalid and may result in a change to your eligibility. In the case of an expired verification of registration/license/certification it will need to be reissued within the above noted 45 day timeframe. Fees are subject to change at any time. The College s Registration Policies are subject to change without notice. Contact the College to ensure you are in possession of the most recent information. I accept the Terms and Conditions above and I acknowledge that acceptance of fees by the College does not constitute approval of registration. Signed Applicant s Signature Date (MM/DD/YYYY) S:\Public\Registration\Application\Application for Dental Assistant Registration.docx College of Alberta Dental Assistants December 2015

8 Section 9: Applicant s Checklist All applicants must submit the following: copy of Canadian government issued identification which states legal name and date of birth (e.g. driver s license, passport) copy of legal documents certifying name change, if applicable copy of documents to verify successful completion of dental education programs if education obtained outside of Canada provide copy of qualification assessment verification of intra-oral upgrading, if applicable verification of registration/license/certification forwarded directly to the College, if applicable explanation of investigation/discipline proceedings, criminal record and/or physical or mental conditions or disorders, if applicable signed and dated Applicant s Statement signed and dated Terms and Conditions fee payable to the College If applying via a labour mobility agreement also submit: verification of registration/license/certification from regulatory body forwarded directly to the College If applying via NDAEB Certificate also submit: if graduate of a CDAC-accredited program provide copy of NDAEB Certificate if graduate of non-accredited program provide copy NDAEB written examination results and CPE results OR verification of intra-oral upgrading if applying three or more years since graduation provide verification of clinical refresher course OR letter from employer verifying length of employment including performing intra-oral duties and approximate number of hours worked If applying for provisional registration also submit: letter from NDAEB confirming scheduled examination date, OR copy NDAEB written examination results and CPE results, OR verification of current student status and completion of intra-oral education OFFICE USE ONLY Educational Institute Skills IMP PF RAD DD BL DES MW PIT SUT TA PRB PCR ORTH SC Signature Section 10: Fee and Payment Information Select appropriate Fee. Full Fee $ Assessment Fee plus $ Registration Fee Prorated Fee* $ Assessment Fee plus $ Registration Fee *Only if applying for registration that begins between June 1 and November 30. If paying by money order you must submit two separate money orders, one for the Assessment Fee and one for the Registration Fee. If paying by credit card your credit card account may be debited in two separate transactions, once for the Assessment Fee and once for the Registration Fee. Payment Method: 2 Money Orders Payment by phone is not available. For credit card payment the Cardholder s signature is required to authorize payment. I hereby authorize College of Alberta Dental Assistants to debit my credit card account Card Number Expiry Date (MM/YYYY) Cardholder Name Cardholder Signature Date Address and phone number of Cardholder if other than Applicant Office Use Only Registration # Full Fee Prorated Fee third party payer Date S:\Public\Registration\Application\Application for Dental Assistant Registration.docx College of Alberta Dental Assistants December 2015

9 College of Alberta Dental Assistants Ave NW Edmonton AB T5L 4S fax Verification of Registration, License or Certification Applicants for registration with the College of Alberta Dental Assistants are required to complete and send this Verification of Registration, License or Certification form to the relevant organization where the applicant is or has been registered, licensed or certified as a dental assistant or any other regulated healthcare professional. Applicants who have been registered, licensed or certified in more than one jurisdiction or profession must complete and send one form to each applicable regulatory body. Part A: Consent for Release To be completed by the applicant and sent, along with Part B, to the applicable regulatory body: I have made application with the College of Alberta Dental Assistants for registration in order to engage in the practice of dental assisting in the province of Alberta. I, therefore, hereby irrevocably authorize and request that: Name of regulatory body (hereinafter referred to as receiving regulatory authority ) provides to the College of Alberta Dental Assistants full disclosure of any and all information the receiving regulatory authority may have respecting my professional conduct, competence and capacity including providing a copy of any written information in my file pertaining to these matters and this shall serve as the receiving regulatory authority s full, final and irrevocable authority for so doing. I understand the legal implications and approve the receiving regulatory authority s release of any information requested by the College of Alberta Dental Assistants. I understand that I have the right to seek legal advice prior to signing this form. Signature of Applicant Print Applicant s Name Applicant s Registration, License or Certificate Number with Receiving Regulatory Authority Date S:\Public\Registration\Letters of Standing\Verification of Registration Form.docx November 2015 The College of Alberta Dental Assistants regulates its members in the public interest, promoting the delivery of safe, quality oral health care.

10 Verification of Registration, License or Certification Part B: Registration/License/Certification Information To be completed by the regulatory body and forwarded directly to the College of Alberta Dental Assistants at: (fax) AVE NW Edmonton Alberta T5L 4S6 Applicant s Registration/License/Certification (R/L/C) Information Name R/L/C Number Profession Dental Assistant Other (provide professional title) The applicant has held R/L/C in Receiving regulatory authority s jurisdiction MM/DD/YYYY MM/DD/YYYY Current Status Practicing/active Non-practicing/inactive Other (specify and provide an explanation) Suspended/cancelled Provisional/temporary/conditional From To Has the applicant ever had terms, restrictions, conditions or limitations on her or his R/L/C? Yes attach a description and the dates in force Has the applicant ever had her or his R/L/C suspended, cancelled, revoked or struck from a Register of your organization? Yes attach a description and the dates in force No No Has the applicant ever been the subject of a formal complaint, investigation or disciplinary proceeding in the nature of professional misconduct, incompetency or incapacity, or a like finding made against her or him? Yes attach a description and the dates in force No Has the applicant always been in compliance with your competence/professional development/quality assurance program requirements? Yes No attach a description and the dates in force Regulatory Body s Information Organization Name and Address Corporate Seal Telephone I certify that the information provided on and attached to this form are true statements of the R/L/C record for the applicant. Signature Print Signatory s Name Date Signatory s Title S:\Public\Registration\Letters of Standing\Verification of Registration Form.docx November 2015

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