Certified Dental Assistant Renewal Application
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- Randall Hardy
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1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Board of Dental Examiners Renewal Clerk (802) Certified Dental Assistant Renewal Application Current Expiration 09/30/2013 Renewal Period Covering 10/01/2013 through 09/30/2015 Renewal Application Fee $75.00 [n Refundable Processing Fee] Checks Payable to: Vermont Secretary of State You Must Complete The Information Below: For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal application fee is non-refundable. If the completed renewal, along with all supporting documentation, is not received in the Office by the expiration date you will be required to pay a late renewal penalty. The penalty is $25.00 for renewals submitted less than 30 days late. Thereafter, the penalty increases by $5.00 for every additional month or fraction of a month, not to exceed $ Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country If your 911 address has changed, indicate your new address in the box to the right. Street/Apt # Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) / / Male Female
2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.
3 Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3
4 Section D: Emergency Office Procedures Board of Dental Examiners, Rule 4.16 Emergency Office Procedures Completion of a course in emergency office procedures as defined in Rule 2.1(m) is required for license renewal. Have you completed a course in emergency office procedures OR a cardiopulmonary resuscitation certification (CPR) course within the last 2 years (10/01/11 09/30/13)? Section E: Supervision Since you were originally registered OR since you completed your last renewal application OR since your most recent update submitted to the office (whichever is later) has there been a change in Supervisor? Name of Supervising Dentist VT Dental License Number Section F: DANB Certification Board of Dental Examiners, Rule 7.8 How to Become Registered as a Certified Dental Assistant (b) Certification must be renewed in accordance with Dental Assisting National Board (DANB) requirements. Certified Dental Assistants, whose certification status has changed, for any reason, must notify the Board of the change in status within 30 days of the change. Do you hold a current registration with the Dental Assisting National Board (DANB)? Name (print): License Number: 4
5 Section G: Expired Renewal If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section H: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant **(REQUIRED)** Signature Date (MM/DD/YYYY) Print Name: License # _ ---- Name (print): License Number: 5
6 Office of Professional Regulation Vermont Secretary of State Attn: Renewal Clerk 89 Main St. 3 rd Floor Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2013 Renewal License #: ---- Name: 1. Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 6
7 21907 VERMONT DEPARTMENT OF HEALTH CENSUS OF DENTAL ASSISTANTS 2013 This census is designed to assess the distribution of dental assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 1 Vermont License Number - (Please print legibly using a dark blue or black pen and uppercase letters; fill in small check ovals entirely) First Name Middle Name Last Name 1. Age: Gender: Male Female 2. Were you born in the USA? If not, where? 4. What is your dental assistant training source? On-the-job training Technical school (e.g., CTE) 5. In what year did you complete your dental assistant training? Daytime Phone Number Are you Hispanic or Latino? 4. Race? (check all that apply) American Indian or Alaska Native Black or African American White Asian Native Hawaiian or Pacific Islander Choose not to respond 6. Enter the two-letter code for the state where you completed your dental assistant training: (use CC for Canada, XX for other foreign countries) Name of other foreign country: 7. Are you certified as an Expanded Function Dental Assistant? 8. What is your highest NON-dental-assistant degree, if any? Certificate/Diploma Associate degree 9. What field is the degree in? Bachelor s degree Master s degree Doctoral degree 10. In what year did you first start working as a dental assistant? 11. In what year did you first start working as a dental assistant IN VERMONT? Please continue on next page. Thank you
8 21907 VERMONT DEPARTMENT OF HEALTH CENSUS OF DENTAL ASSISTANTS 2013 This census is designed to assess the distribution of dental assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 2 Vermont License Number (Please re-enter your license number for scanning purposes) 12. Please describe your current employment status: (check all that apply) Actively working as a certified dental assistant Actively working in a dental field but not as a certified dental assistant Actively working in a non-dental field t currently working, disabled Seeking work as a certified dental assistant Seeking work but not as a certified dental assistant Student Leave of absence or Sabbatical Retired 13. What state(s) are you currently practicing in as a dental assistant? 14. If you are not currently working as a dental assistant, are you planning on returning in the next 12 months? Unsure * IF you are not actively working IN VERMONT as a certified dental assistant, PLEASE STOP HERE AND RETURN SURVEY 15. Are you currently working as many hours as you would like as a dental assistant? 16. If NO, how many ADDITIONAL hours a week would you like to be working as a dental assistant? 17. What are your employment plans for the next 12 months? Increase hours in patient care Decrease hours in patient care Seek employment in a field outside of patient care Leave direct patient care to complete further training Leave direct patient care for family reasons/commitments Leave direct patient care due to physical demands Leave direct patient care due to stress/burnout Retire 6. Do you plan Continue to retire as or you reduce are your patient care hours in the next 12 months? Please continue on next page. Thank you
9 21907 VERMONT DEPARTMENT OF HEALTH CENSUS OF DENTAL ASSISTANTS 2013 This census is designed to assess the distribution of dental assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 3 Vermont License Number (Please re-enter your license number for scanning purposes) - Please enter site information FOR EACH LOCATION where you treat patients IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. Hours spent TREATING PATIENTS should include diagnosis, treatment planning, direct care and clinical report. SITE ONE (principal site) - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): This site is a (please choose ONE): Practice of one dentist Practice of 2 dentists Practice of 3 or more dentists Rural / Community Health Center Extended Care / Nursing Home Hospital / Clinic (outpatient) Hospital dentistry (inpatient) Home Health Local Health Department (Public Health) Public Health / Community Health Setting School Health Service (e.g., Tooth Tutors) Mobile Unit Dentistry Correctional Facility Head Start (including Early HS) Which best describes the dentist(s) or organization for whom you work at this practice location? General dentist Pediatric dentist Orthodontist Periodontist Endodontist Prosthodontist Oral & Maxillofacial Surgeon Please enter the total number of WEEKS in a year during which you work at this site. 48 weeks is considered "year round". Weeks Per Year Please enter the average HOURS per week you work here during the weeks you work at this site: Direct Patient Care Education Administration Case Management Research Please return all sheets (6 pages) even if some are blank. Thank you
10 21907 VERMONT DEPARTMENT OF HEALTH CENSUS OF DENTAL ASSISTANTS 2013 This census is designed to assess the distribution of dental assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 4 Vermont License Number (Please re-enter your license number for scanning purposes) - Please enter site information FOR EACH LOCATION where you treat patients IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. Hours spent TREATING PATIENTS should include diagnosis, treatment planning, direct care and clinical report. SITE TWO (if any) - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): This site is a (please choose ONE): Practice of one dentist Practice of 2 dentists Practice of 3 or more dentists Rural / Community Health Center Extended Care / Nursing Home Hospital / Clinic (outpatient) Hospital dentistry (inpatient) Home Health Local Health Department (Public Health) Public Health / Community Health Setting School Health Service (e.g., Tooth Tutors) Mobile Unit Dentistry Correctional Facility Head Start (including Early HS) Which best describes the dentist(s) or organization for whom you work at this practice location? General dentist Pediatric dentist Orthodontist Periodontist Endodontist Prosthodontist Oral & Maxillofacial Surgeon Please enter the total number of WEEKS in a year during which you work at this site. 48 weeks is considered "year round". Weeks Per Year Please enter the average HOURS per week you work here during the weeks you work at this site: Direct Patient Care Education Administration Case Management Research Please return all sheets (6 pages) even if some are blank. Thank you
11 21907 VERMONT DEPARTMENT OF HEALTH CENSUS OF DENTAL ASSISTANTS 2013 This census is designed to assess the distribution of dental assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 55 Vermont License Number (Please re-enter your license number for scanning purposes) - Please enter site information FOR EACH LOCATION where you treat patients IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. Hours spent TREATING PATIENTS should include diagnosis, treatment planning, direct care and clinical report. SITE THREE - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): This site is a (please choose ONE): Practice of one dentist Practice of 2 dentists Practice of 3 or more dentists Rural / Community Health Center Extended Care / Nursing Home Hospital / Clinic (outpatient) Hospital dentistry (inpatient) Home Health Local Health Department (Public Health) Public Health / Community Health Setting School Health Service (e.g., Tooth Tutors) Mobile Unit Dentistry Correctional Facility Head Start (including Early HS) Which best describes the dentist(s) or organization for whom you work at this practice location? General dentist Pediatric dentist Orthodontist Periodontist Endodontist Prosthodontist Oral & Maxillofacial Surgeon Please enter the total number of WEEKS in a year during which you work at this site. 48 weeks is considered "year round". Weeks Per Year Please enter the average HOURS per week you work here during the weeks you work at this site: Direct Patient Care Education Administration Case Management Research Please return all sheets (6 pages) even if some are blank. Thank you
12 21907 VERMONT DEPARTMENT OF HEALTH CENSUS OF DENTAL ASSISTANTS 2013 This census is designed to assess the distribution of dental assistants throughout the state and assist in recruitment and retention efforts. If you have any questions, please contact the Department of Health at (802) or Thank you for your cooperation. 65 Vermont License Number (Please re-enter your license number for scanning purposes) - Please enter site information FOR EACH LOCATION where you treat patients IN VERMONT. If you provide care at two locations in the same town, please enter a separate site for each. Hours spent TREATING PATIENTS should include diagnosis, treatment planning, direct care and clinical report. SITE FOUR - town for the Vermont location where you work, not a mailing address: Street address (not a mailing address): This site is a (please choose ONE): Practice of one dentist Practice of 2 dentists Practice of 3 or more dentists Rural / Community Health Center Extended Care / Nursing Home Hospital / Clinic (outpatient) Hospital dentistry (inpatient) Home Health Local Health Department (Public Health) Public Health / Community Health Setting School Health Service (e.g., Tooth Tutors) Mobile Unit Dentistry Correctional Facility Head Start (including Early HS) Which best describes the dentist(s) or organization for whom you work at this practice location? General dentist Pediatric dentist Orthodontist Periodontist Endodontist Prosthodontist Oral & Maxillofacial Surgeon Please enter the total number of WEEKS in a year during which you work at this site. 48 weeks is considered "year round". Weeks Per Year Please enter the average HOURS per week you work here during the weeks you work at this site: Direct Patient Care Education Administration Case Management Research Please return all sheets (6 pages) even if some are blank. Thank you
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