Dental Office Compliance Manual - the Ohio State Dental Board ...

OHIO STATE DENTAL BOARDDental OfficeComplianceManual

OHIO STATE DENTAL BOARDDental Office Compliance ManualOhio State Dental Board77 South High Street • 17th FloorColumbus, Ohio 43215-6135Phone 614.466.2580 • Fax 614.752.8995www.dental.ohio.govdental.board@den.state.oh.usSeptember 18, 2012

ContentsDENTAL PERSONNEL DOCUMENTATION ......................................................................................1DENTIST(S) ................................................................................................................................................1Board Documentation...........................................................................................................................1Display Of License To Practice Dentistry - RI ................................................................................1Current Licensure Renewal Receipt Card - RI.................................................................................2Certificate Of Anesthesia/Conscious Sedation Permit – RI.............................................................2Oral Health Access Supervision Permit – RI ...................................................................................2Current OHASP Permit Renewal Receipt Card - RI........................................................................2Other Documentation............................................................................................................................2Hepatitis B Virus Inoculation Record – RO.....................................................................................2Drug Enforcement Administration Registration – RO.....................................................................3Ohio Automated Rx Reporting System (OARRS) Registration – RO ............................................3DENTAL HYGIENIST(S)..............................................................................................................................6Board Documentation...........................................................................................................................6Display Of License To Practice Dental Hygiene - RI ......................................................................6Current Licensure Renewal Receipt Card - RI.................................................................................6Expanded Function Dental Auxiliary Registration - RI...................................................................6Current EFDA Renewal Receipt Card - RI ......................................................................................6Oral Health Access Supervision Permit - RI....................................................................................6Current OHASP Permit Renewal Receipt Card - RI........................................................................7Permissible Practices Documentation for Dental Hygienists Form – R ..........................................7Permissible Practices Documentation for Dental Hygienists Form - FYI .......................................7Other Documentation............................................................................................................................7Hepatitis B Virus Inoculation Record - RO......................................................................................7Cardiopulmonary Resuscitation (CPR) Certificate – RO.................................................................8DENTAL ASSISTANT(S)..............................................................................................................................9Board Documentation...........................................................................................................................9Dental Assistant Radiographer Certificate - RI................................................................................9Current Renewal Receipt Card - RI..................................................................................................9Coronal Polishing Certificate - RI ....................................................................................................9Expanded Function Dental Auxiliary Registration - RI...................................................................9Current EFDA Renewal Receipt Card - RI ......................................................................................9Permissible Practices Documentation for Dental Assistants Form - R............................................9Permissible Practices Documentation for Dental Assistants Form - FYI......................................10Other Documentation..........................................................................................................................10Hepatitis B Virus Inoculation Record - RO....................................................................................10Cardiopulmonary Resuscitation (CPR) Certificate - RO ...............................................................11OFFICE DOCUMENTATION ...............................................................................................................12BOARD.....................................................................................................................................................12Current Dental Practice Act ...............................................................................................................12Infection Control Manual ...................................................................................................................12Infection Control Evaluation Form ....................................................................................................12OTHER .....................................................................................................................................................12Ohio State Board of Pharmacy...........................................................................................................12Ohio Department of Health X-Ray Inspection ...................................................................................12Occupational Safety and Health Administration (OSHA)..................................................................12Environmental Protection Agency (EPA)...........................................................................................13Drug Enforcement Administration (DEA)..........................................................................................13Reporting Requirements for Child and Elder Abuse..........................................................................13ADDITIONAL REQUIREMENTS AND RESOURCES .....................................................................14FORMS ......................................................................................................................................................15PERMISSIBLE PRACTICES DOCUMENTATION FOR DENTAL HYGIENISTS FORM .....................................15PERMISSIBLE PRACTICES DOCUMENTATION FOR DENTAL ASSISTANTS FORM .....................................15INFECTION CONTROL EVALUATION FORM .............................................................................................16

Introduction:The Ohio State Dental Board’s (Board) Dental Office ComplianceManual is intended to provide a guideline for licensees to follow tomaintain compliance with the provisions set forth in Ohio RevisedCode and Ohio Administrative Code Chapters 4715. Additionally,links to other government regulatory websites have been providedin Sections 2: Office Documentation and 3: AdditionalRequirements and Resources. The manual is meant to assist,enhance and clarify the Board’s laws and rules regarding requireddocumentation for the dental practice. It is subject to revision atthe Board’s discretion without notice to the public. References tovarious resource materials are indicated throughout the document.

DENTAL PERSONNEL DOCUMENTATIONSection1Dental Personnel DocumentationAll dental personnel who provide dental services in the dental practice, whether they are the employeror employee dentist, the dental hygienist, the certified dental assistant, the expanded function dentalauxiliary, and/or the dental assistant, may be required or recommended to have documents availablefor review by regulatory agencies, such as the Ohio State Dental Board (Board), or for their owninformation purposes. The documentation as listed in the manual is either:• required and issued by the Ohio State Dental Board (RI); or• required by the Ohio State Dental Board (R); or• required by another regulatory agency (RO), or• recommended for informational purposes (FYI).Dentist(s)Board DocumentationDisplay Of License To Practice Dentistry - RIThe Dental Practice Act, Chapter 4715 of the Ohio Revised Code (ORC) and Ohio Administrative Code(OAC), stipulates that all licensed dentists in the state of Ohio must display the license, as granted by theBoard, in a conspicuous place in the office wherein they practice the majority of the time. [See ORC4715.17]1

DENTAL PERSONNEL DOCUMENTATIONCurrent Licensure Renewal Receipt Card - RIBeginning with the first renewal period, and by January first of every even year thereafter, each licenseddentist is required to register with the Board. Upon receipt of the completed licensure renewal application,renewal fee, and attestation that the licensee has completed 40 hours of continuing dental education as setforth in ORC 4715.141 and OAC 4715-8-01, the Board will issue a Renewal Receipt Card. [See ORC4715.14] Additionally, the license remains in good standing until the first day of April of the new biennialrenewal period. At that time, if the license is not renewed, the license is automatically suspended by theBoard and may be subject to disciplinary action.Certificate Of Anesthesia/Conscious Sedation Permit – RIWith the exception of nitrous oxide-oxygen (N 2 O-O 2 ), any appropriately trained dentist who wishes toadminister general anesthesia or deep sedation [See ORC 4715.09(E) and 4715.13 (A)(3)] or conscioussedation [4715.13(A)(4)] must apply to the Board for a(n) Anesthesia or Conscious Sedation Permit.Information regarding application, education, training, facilities, and equipment may be found in sectionsOAC 4715-5-05 (Anesthesia Permit) or OAC 4715-5-07 (Conscious Sedation Permit).Oral Health Access Supervision Permit – RIAny dentist who desires to participate in the Oral Health Access Supervision Program (OHASP) must firstapply to the Board to receive a permit. [See ORC 4715.362]Information regarding authority, protocols, and permissible delegable duties may be found in ORC sections4715.36 to 4715.375 and OAC 4715-9-05, 4715-9-06 and 4715-9-06.1.Current OHASP Permit Renewal Receipt Card - RIAny dentist wishing to continue participating in OHASP, who has remained in good standing with theBoard, must renew the OHASP permit by January first of every even year. The Board will issue anOHASP Permit Renewal Receipt Card upon receipt of the completed OHASP permit renewal application,renewal fee, and verification of the following:• the locations wherein the dental hygienist has provided services under the dentist’s supervision; and• the number of patients who have received dental hygiene services; and• the number of patients receiving dental hygiene services who were subsequently clinically evaluatedby the dentist holding the OHASP permit.[See ORC 4715.369]Other DocumentationHepatitis B Virus Inoculation Record – ROThis applies to all dental health care workers, i.e. dentists and persons utilized by the dentist, who assist inthe dental practice and who may be exposed to body fluids such as blood and saliva. The first shot isrequired prior to patient contact. The most common vaccination schedule is given intramuscularly three (3)times over a six (6) month period:• First shot2

DENTAL PERSONNEL DOCUMENTATION• Second shot received after 30 days but less than 60 days from initial inoculation• Third shot received six (6) months from date of initial inoculationMedical documentation for the dental health care worker indicating the dates of each inoculation in theseries will be considered acceptable by the Board if signed by any of the following entities but not limitedto:• Licensed Physician;• Licensed Nurse;• Ohio Department of Health or local health department employee; or• Documentation from a college or university health service, etc.Attestation forms or forms completed and signed by the dental health care worker are not consideredacceptable medical documentation. Dental health care workers who are unable to provide acceptablemedical documentation may obtain a blood titer indicating immunity to the Hepatitis B virus. Acceptabletiter results are as follows:• Reactive; or• Positive; or• > 9.9Those who have had Hepatitis B must show immunity with the appropriate titer testing documentation.Waiver - RIThe Board may waive the inoculation requirements if it is determined that a waiver is justified based onmedical documentation indicating that the immunization threatens the health and well-being of theindividual. Any Board-approved waiver must be renewed according to the discretion of the Board. Anyperson who is medically unable to receive the HBV inoculations must apply and be approved for a waiverfrom the Board. A “Hepatitis B Waiver Request” is available on the Board’s website, www.dental.ohio.govWaivers are based on medical documentation from your physician.Drug Enforcement Administration Registration – ROhttp://www.deadiversion.usdoj.gov/drugreg/index.htmlOhio Automated Rx Reporting System (OARRS) Registration – ROThe Ohio Automated Rx Reporting System (OARRS) was established in 2006 as a tool to assist healthcareprofessionals in providing better treatment for patients with medical needs while quickly identifying drugseeking behaviors. An OARRS Prescription History Report can assist in assuring that a patient is getting theappropriate drug therapy and is taking their medication as prescribed.Prescribers, pharmacists and officers of law enforcement agencies whose primary mission involvesenforcing prescription drug laws can register for an OARRS account. Registered prescribers may alsopermit delegates to register for an OARRS account in order to request Prescription History Reports on theprescriber's behalf.3

DENTAL PERSONNEL DOCUMENTATIONOARRS Terminal Distributor AccountGo to www.ohiopmp.gov and select “Click here to register” in order to obtain an Ohio Automated RxReporting System (OARRS) Terminal Distributor Account and complete the instructions as follows:Before you start, make a copy of your driver’s license, professional license card, and DEAregistration certificate.Step 1 – Go to www.ohiopmp.gov. Click on the link below the login which says “Click here toregister”.Step 2 – Choose “Healthcare Professional/Law Enforcement.” Click “Next.”Step 3 – Enter your driver’s license number. Click “Submit.”Step 4 – Select your Account type – Choose “Prescriber (includes Physician Assistant with prescriptiveauthority and Nurse Practitioner with prescriptive authority)”Step 5 – Read and approve the Acceptable Use Policy – Note: you may not share your user nameand password with anyone else, including office staff. Click “Approve” at the bottom ofthe page to continue.Step 6 – Complete the application(A) Enter your personal and professional information.(B) Provide the e-mail address that you want OARRS to use when communicating withyou.(C) You must answer three security questions. For each security question, there are fiveoptions. Click on the down arrow to view alternate questions.(D) Click “Submit” to proceed.(E) Before printing your application, you must verify your e-mail address by retrieving a 6-digit verification code. The verification code will be in an email fromSupport@ohiopmp.gov. If you don’t see the e-mail within 30 minutes of submittingyour application, check your spam or junk mail folder.Step 7 – Edit or Retrieve your Application.(A) If you are not already at the page requesting your verification code, go towww.ohiopmp.gov and choose “Click here to register” again. Select “Healthcare Professional/Law Enforcement” and enter your driver’s license number.(B) Enter Verification Code: Enter the 6-digit verification code and click “Submit.”(C) Edit Application if necessary.(D) Print Application. If you get a “File Damaged” error, try another computer with upto-dateAdobe PDF software.Step 8 – Sign, notarize, and mail.(A) Sign your application in the presence of a public notary.4

DENTAL PERSONNEL DOCUMENTATION(B)Mail your notarized application and the photocopy of your driver’s license,professional license card, and DEA registration to the address on the application.If your application is approved, you will receive a user name by e-mail and password bypostal mail to your home. If you do not receive both within 10 business days of mailing yourapplication, please email OARRS at support@ohiopmp.gov or call 614-466-4143 (Option 1).Additional InformationAs a prescriber, we understand that it is sometimes difficult to take time out of your schedule torequest OARRS reports. For this reason, prescribers are permitted to appoint delegates to requestOARRS reports on their behalf. EACH DELEGATE MUST HAVE HIS/HER OWNACCOUNT.Two types of delegate accounts are offered:Licensed Delegate: A licensed delegate must hold a healthcare professional license (RN, LPN, PA,RDH, etc.). A prescriber may have multiple licensed delegates. A delegate account may be supervisedby multiple prescriber accounts. Each supervising prescriber must sign the delegate’s OARRSapplication form, or an “Add/Remove Delegate” form*, to accept responsibility for the OARRS activityof the delegate.Unlicensed Delegate: An unlicensed delegate is not required to hold any healthcare professionallicense. This type of account is appropriate for a medical assistant or an office manager. A prescribermay have up to three (3) unlicensed delegates. An unlicensed delegate account may be supervised bymultiple prescriber accounts.Before an unlicensed delegate’s application can be completed, at least one supervisor mustelectronically approve the application. This is done by simply logging into OARRS. You will beautomatically prompted:“The following applications have been submitted to request an OARRS unlicensed delegate account underyour supervision. Please be aware that you are limited to 3 unlicensed delegates.”You may approve or deny any of the delegate registrations listed. You will also have the option toskip this page to continue to the OARRS WebCenter and be prompted again later.Each supervising prescriber must sign the appropriate area of the delegate’s application to acceptresponsibility for the OARRS activity of the delegate. If additional supervising prescribers are desiredthat were not chosen during the registration process, these prescribers can use the “Add/RemoveDelegate Form”* to be added as a supervising prescriber for the delegate.*This form is available on the OARRS website under “Related Links”, after you log in. The sameform may also be used whenever a delegate is no longer under your supervision.If you have any problems, please contact OARRS support by email at support@ohiopmp.gov or byphone at 614-466-4143 (Option 1).5

DENTAL PERSONNEL DOCUMENTATIONDental Hygienist(s)Board DocumentationDisplay Of License To Practice Dental Hygiene - RIThe Dental Practice Act, Chapter 4715 of the Ohio Revised Code (ORC) and Ohio Administrative Codes(OAC), stipulates that all licensed dental hygienists in the State of Ohio must display the license, as grantedby the Board, in a conspicuous place in the room wherein they practice the majority of the time. [See ORC4715.24(C)]Current Licensure Renewal Receipt Card - RIBeginning with the first renewal period, and by January first of every even year thereafter, each licenseddental hygienist is required to register with the Board. Upon receipt of the completed renewal application,renewal fee, and attestation that the licensee has completed 24 hours of continuing dental hygiene educationas set forth in ORC 4715.25 and OAC 4715-8-01, and attestation/proof of completion of cardiopulmonaryresuscitation (CPR) [See ORC 4715.251], the Board will issue a Renewal Receipt Card. [See ORC 4715.24]At that time, if the license is not renewed, the license is automatically suspended by the Board and may besubject to disciplinary action.Expanded Function Dental Auxiliary Registration - RIAny appropriately trained dental hygienist who wishes to perform the functions of an Expanded FunctionDental Auxiliary (EFDA) must first apply to the Board for an EFDA Registration. Information regardingapplication, education and training, renewal and permissible practices may be found in ORC sections4715.61 to 4715.66 and OAC 4715-11-04 to 4715-11-04.3.Current EFDA Renewal Receipt Card - RIUpon receipt of the completed EFDA renewal application and renewal fee, the Board will issue a RenewalReceipt Card. [See ORC 4715.63]Oral Health Access Supervision Permit - RIAny dental hygienist who desires to participate in the Oral Health Access Supervision Program (OHASP)must first apply to the Board to receive a permit. [See ORC 4715.363] In order to be granted a permit topractice in OHASP, the licensed dental hygienist must have completed the following:• At least two (2) years and 3,000 hours of clinical dental hygiene practice; and• An OHASP course specifically regarding the treatment of geriatric, medically compromised,developmentally disabled, and or pediatric patients, infection control, ethical and legalconsiderations, and recordkeeping practices; and• Within two (2) years immediately preceding the application:• At least 24 hours of continuing dental hygiene education; and6

DENTAL PERSONNEL DOCUMENTATION• A course pertaining to the identification and prevention of potential medical emergencies.Information regarding authority under the permit, protocols, and permissible practices may be found inORC sections 4715.36 to 4715.375 and OAC 4715-9-05, 4715-9-06 and 4715-9-06.1.Current OHASP Permit Renewal Receipt Card - RIAny dental hygienist wishing to continue participating in OHASP, who has remained in good standing withthe Board, must renew the OHASP permit by January first of every even year. The Board will issue anOHASP Permit Renewal Receipt Card upon receipt of the completed OHASP permit renewal application,renewal fee, and verification of the following:• the locations wherein the dental hygienist has provided services under the dentists supervision; and• the number of patients who have received dental hygiene services.[See ORC 4715.37]Permissible Practices Documentation for Dental Hygienists Form – RThe Permissible Practices Documentation for the Dental Hygienists Form is required for any licenseddental hygienist who wishes to administer and/or monitor nitrous oxide-oxygen (N 2 O-O 2 ) minimalsedation and has completed the following:• appropriate education, training, and examination requirements to administer nitrous oxide-oxygen(N 2 O-O 2 ) minimal sedation [See OAC 4715-9-01.2]; and/or• appropriate education and examination requirements to monitor nitrous oxide-oxygen (N 2 O-O 2 )minimal sedation [See OAC 4715-9-01.3 and 4715-11-02.1].Permissible Practices Documentation for Dental Hygienists Form - FYIThe Permissible Practices Documentation for the Dental Hygienists Form is recommended for anyappropriately trained and qualified licensed dental hygienist who desires to perform the following functions:• Administration of intraoral block and infiltration local anesthesia[See ORC 4715.231 and OAC4715-9-01.1]; and/or• Expanded function dental auxiliary (EFDA)• Practice when the dentist is not physically present [See ORC 4715.22 and OAC 4715-9-05]This form is also available in Section 4 of this manual or on the Board’s website at:http://www.dental.ohio.gov/forms/dhdocumentation.pdfOther DocumentationHepatitis B Virus Inoculation Record - ROThis applies to all dental health care workers, i.e. dentists and persons utilized by the dentist, who assist inthe dental practice and who may be exposed to body fluids such as blood and saliva. The first shot isrequired prior to patient contact. The most common vaccination schedule is given intramuscularly three (3)times over a six (6) month period:• First shot• Second shot received after 30 days but less than 60 days from initial inoculation7

DENTAL PERSONNEL DOCUMENTATION• Third shot received six (6) months from date of initial inoculationMedical documentation for the dental health care worker indicating the dates of each inoculation in theseries will be considered acceptable by the Ohio State Dental Board (Board) if signed by any of thefollowing entities but not limited to:• Licensed Physician;• Licensed Nurse;• Ohio Department of Health or local Health Department employee; or• Documentation from a College or University Health Service, etc.Attestation forms or forms completed and signed by the dental health care worker are not consideredacceptable medical documentation. Dental health care workers who are unable to provide acceptablemedical documentation may obtain a blood titer indicating immunity to the Hepatitis B virus. Acceptabletiter results are as follows:• Reactive; or• Positive; or• > 9.9Waiver - RIThe board may waive the inoculation requirements if the board determines that such waiver is justifiedbased on medical documentation indicating that such immunization threatens the health and well-being ofthe individual. Any board-approved waiver must be renewed according to the discretion of the Board. Anyperson who is medically unable to receive the HBV inoculations must apply and be approved for a waiverfrom the Board. A “Hepatitis B Waiver Request” is available on the Board’s website, www.dental.ohio.govThese waivers are based on medical documentation from your physician. Those who have had Hepatitis Bmust show immunity with the appropriate titer testing documentation.Cardiopulmonary Resuscitation (CPR) Certificate – ROThe Dental Practice Act stipulates that all licensed dental hygienists in the State of Ohio must be currentlycertified in basic life support and provide evidence of current completion of cardiopulmonary resuscitation(CPR) at the time of licensure renewal. Acceptable CPR certification may be obtained through any of thefollowing organizations:• American Red Cross (ARC); or• American Heart Association (AHA); or• American Safety and Health Institute (ASHI).[See ORC 4715.251]8

DENTAL PERSONNEL DOCUMENTATIONDental Assistant(s)Board DocumentationDental Assistant Radiographer Certificate - RIThe Dental Practice Act, Chapter 4715 of the Ohio Revised Code (ORC) and Ohio Administrative Codes(OAC), stipulates that all dental assistants in the state of Ohio, who perform standard, diagnostic, radiologicprocedures, must obtain a certificate from the Board in order to perform these functions. [See ORC4715.52]Current Renewal Receipt Card - RIBeginning with the first renewal period, and by January first of every odd year thereafter, each dentalassistant radiographer is required to register with the Board. Upon receipt of the completed renewalapplication, renewal fee, and attestation that the certificate holder has completed 2 hours of continuingeducation in radiology as set forth in ORC 4715.53(C) and OAC 4715-12-03, the Board will issue aRenewal Receipt Card. At that time, if the certificate is not renewed, the certificate is automaticallysuspended by the Board and may be subject to disciplinary action.Coronal Polishing Certificate - RIAny appropriately trained currently certified dental assistant who wishes to perform coronal polishing mustfirst apply to the Board for a Coronal Polishing Certificate. Information regarding application, educationand training, examination requirements and permissible practices may be found in ORC section 4715.39and OAC 4715-11-03(B)(2) and 4715-11-03.1.Expanded Function Dental Auxiliary Registration - RIAny appropriately trained currently certified dental assistant who wishes to perform the functions of anExpanded Function Dental Auxiliary (EFDA) must first apply to the Board for an EFDA Registration.Information regarding application, education and training, renewal and permissible practices may be foundin ORC sections 4715.61 to 4715.66 and OAC 4715-11-04 to 4715-11-04.3.Current EFDA Renewal Receipt Card - RIUpon receipt of the completed EFDA renewal application and renewal fee, the Board will issue a RenewalReceipt Card. [See ORC 4715.63]Permissible Practices Documentation for Dental Assistants Form - RThe Permissible Practices Documentation for the Dental Assistants Form is required for any licenseddental assistant who wishes to monitor nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation and hascompleted the appropriate education and examination requirements to monitor nitrous oxide-oxygen(N 2 O-O 2 ) minimal sedation. [See OAC 4715-11-02.1]9

DENTAL PERSONNEL DOCUMENTATIONPermissible Practices Documentation for Dental Assistants Form - FYIThe Permissible Practices Documentation for the Dental Assistants Form is recommended for anyappropriately trained and qualified dental assistant who performs the following functions:• Dental assistant radiography;• Pit and fissure sealants;• Coronal polishing;• Expanded function dental auxiliary (EFDA)This form is also available in Section 4 of this manual or on the Board’s website at:http://www.dental.ohio.gov/forms/dadoc.pdfOther DocumentationHepatitis B Virus Inoculation Record - ROThis applies to all dental health care workers, i.e., dentists and persons utilized by the dentist, who assist inthe dental practice and who may be exposed to body fluids such as blood and saliva. The first shot isrequired prior to patient contact. The most common vaccination schedule is given intramuscularly three (3)times over a six (6) month period:• First shot• Second shot received after 30 days but less than 60 days from initial inoculation• Third shot received six (6) months from date of initial inoculationMedical documentation for the dental health care worker indicating the dates of each inoculation in theseries will be considered acceptable by the Ohio State Dental Board (Board) if signed by any of thefollowing entities but not limited to:• Licensed Physician;• Licensed Nurse;• Ohio Department of Health or local Health Department employee; or• Documentation from a College or University Health Service, etc.Attestation forms or forms completed and signed by the dental health care worker are not consideredacceptable medical documentation. Dental health care workers who are unable to provide acceptablemedical documentation may obtain a blood titer indicating immunity to the Hepatitis B virus. Acceptabletiter results are as follows:• Reactive; or• Positive; or• > 9.9Waiver - RIThe board may waive the inoculation requirements if the board determines that such waiver is justifiedbased on medical documentation indicating that such immunization threatens the health and well-being ofthe individual. Any board-approved waiver must be renewed according to the discretion of the Board. Anyperson who is medically unable to receive the HBV inoculations must apply and be approved for a waiverfrom the Board. A “Hepatitis B Waiver Request” is available on the Board’s website, www.dental.ohio.gov10

DENTAL PERSONNEL DOCUMENTATIONThese waivers are based on medical documentation from your physician. Those who have had Hepatitis Bmust show immunity with the appropriate titer testing documentation.Cardiopulmonary Resuscitation (CPR) Certificate - ROThe Dental Practice Act stipulates that all currently certified dental assistants in the State of Ohio mustremain currently certified in basic life support and provide evidence of current completion ofcardiopulmonary resuscitation (CPR) at all times when monitoring nitrous oxide-oxygen (N 2 O-O 2 ) minimalsedation. Acceptable CPR certification may be obtained through any of the following organizations:• American Red Cross (ARC); or• American Heart Association (AHA); or• American Safety and Health Institute (ASHI).[See ORC 4715.251]11

OFFICE DOCUMENTATIONSection2Office DocumentationBoardCurrent Dental Practice Acthttp://www.dental.ohio.gov/pdfs/2011.dpa.pdfInfection Control Manualhttp://www.dental.ohio.gov/icmanual.pdfInfection Control Evaluation Formhttp://www.dental.ohio.gov/forms/icfform.pdfOtherOhio State Board of Pharmacyhttp://www.pharmacy.ohio.govOhio Department of Health X-Ray InspectionGeneral Information:http://www.odh.ohio.gov/odhprograms/rp/xequip/xequip1.aspxRegistration and inspection information:http://www.odh.ohio.gov/odhprograms/rp/registration/xrayequipment.aspxOccupational Safety and Health Administration (OSHA)General Information:http://www.osha.gov12

OFFICE DOCUMENTATIONRequirements for dental offices:http://www.osha.gov/SLTC/dentistry.index.htmlEnvironmental Protection Agency (EPA)General Information:http://www.epa.ohio.govProper disposal of sharps and medical waste:http://www.epa.ohio.gov/portals/34/document/guidance/gd_075.pdfDrug Enforcement Administration (DEA)Registration, name/address change and practitioner’s manual:http://www.deadiversion.usdoj.gov/drugreg/index.htmlReporting Requirements for Child and Elder AbuseDuty to Report Child Abuse:http://www.codes.ohio.gov/orc/2151.421Abused Child Defined:http://www.codes.ohio.gov/orc/2151.031Neglected Child Defined:http://www.codes.ohio.gov/orc/2151.03Duty to Report Elder Abuse:http://www.codes.ohio.gov/orc/5101.61Helpful Definitions Regarding Elder Abuse:http://www.codes.ohio.gov/orc/5101.6013

ADDITIONAL REQUIREMENTS AND RESOURCESSection3Additional Requirements andResourcesAmerican Dental Associationhttp://www.ada.orgOhio Dental Associationhttp://www.oda.orgAmerican Dental Hygienists’ Associationhttp://www.adha.orgOhio Dental Hygienists’ Associationhttp://www.odha.netAmerican Dental Assistants Associationhttp://www.dentalassistant.orgCDC, Morbidity and Mortality Weekly Reporthttp://www.cdc.gov/mmwrEPA, Antimicrobial Chemicalshttp://epa.gov/oppad001/chemregindex.htmFDAhttp://www.fda.govOSHA, Dentistry, Bloodborne Pathogenshttp://www.osha.gov/SLTC/dentistry/index.htmlhttp://www.osha.gov/SLTC/bloodbornepathogens/index.html

FORMSSection4FormsPermissible Practices Documentation for Dental HygienistsFormIf required, [See explanations in Section 1] the Permissible Practices Documentation for the Dental Hygienists Form isto be completed and maintained in the dental office in which the dental hygienist is performing any ofthe following functions:• Administration of intraoral block and infiltration local anesthesia• Administration of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation• Monitoring of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation• Expanded function dental auxiliary (EFDA)• Practice when the dentist is not physically presentThis form is also available on the Board’s website at:http://www.dental.ohio.gov/forms/dhdocumentation.pdfPermissible Practices Documentation for Dental AssistantsFormIf required, [See explanations in Section 1] the Permissible Practices Documentation for the Dental Assistants Form isto be completed and maintained in the dental office in which the dental assistant is performing any of thefollowing functions:• Monitoring of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation• Dental assistant radiography;• Pit and fissure sealants;• Coronal Polishing;• Expanded Function Dental Auxiliary (EFDA)This form is also available on the Board’s website at:15

FORMShttp://www.dental.ohio.gov/forms/dadoc.pdfInfection Control Evaluation FormThe Infection Control Evaluation Form is used by the Board during infection control inspections and may beutilized by dental offices to assist them in achieving compliance with the Dental Practice Act in regards toinfection control.This form is also available on the Board’s website at:http://www.dental.ohio.gov/forms/icfform.pdf16

OHIO STATE DENTAL BOARD77 South High Street, 17 th floorColumbus, Ohio 43215-6135Phone: 614-466-2580 · Fax: 614-752-8995www.dental.ohio.govPERMISSIBLE PRACTICES DOCUMENTATION FOR DENTAL HYGIENISTSTHIS FORM AND ALL SUPPORTING DOCUMENTATION MUST BE ATTACHED AND MAINTAINED IN THE DENTAL OFFICE WHERETHE DENTAL HYGIENIST IS PRACTICING THE FOLLOWING DUTIES AND OR PROCEDURES:Administration of intraoral block and infiltration local anesthesia (complete Section 3)Administration of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation (complete Section 4)Monitoring of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation (complete Section 5)Expanded Function Dental Auxiliary Registration (complete Section 6)Practice when the dentist is not physically present (complete Section 7)Cardiopulmonary Resuscitation (CPR) certificate (complete Section 8)YOU MUST HAVE COMPLETED A BASIC LIFE-SUPPORT TRAINING COURSE CERTIFIED BY THE AMERICAN HEARTASSOCIATION, THE AMERICAN RED CROSS OR THE AMERICAN SAFETY AND HEALTH INSTITUTE AND REMAIN CURRENTAT ALL TIMES WHEN PERFORMING ANY OF THE DUTIES/FUNCTIONS OUTLINED IN THIS DOCUMENT.ALL SECTIONS OF THIS DOCUMENT MUST BE COMPLETED INDICATING THE DUTIESAND/OR FUNCTIONS YOU HAVE BEEN APPROPRIATELY TRAINED/EDUCATED TO PROVIDE.IF YOU DO NOT MEET THE SPECIFIC REQUIREMENTS TO PERFORM THESEDUTIES/FUNCTIONS, CHECK THE APPROPRIATE BOX IN THAT SECTION.SECTION 1LICENSE/CERTIFICATE HOLDER INFORMATIONName: Ohio License #:Other Names Used: EFDA Registration #:OHASP Permit #:SECTION 2SUPERVISING DENTIST INFORMATIONName: License #:Name of Practice:Address:City: State: Zip Code:Definition: As supervising dentist, I have evaluated the above-named dental hygienist's skills and I have made a determination that thisdental hygienist has received the appropriate training and/or examination requirements for all permissible duties indicated on this form and iscompetent to perform them. I further attest that the information contained herein is true and accurate to the best of my knowledge and belief:Name (print):Date:Signature:

SECTION 3ADMINISTRATION OF INTRAORAL BLOCK AND INFILTRATION LOCAL ANESTHESIAIn order to be allowed to perform this function, you MUST be currently certified to perform basic life support through the AHA, ARC, or ASHI. Acopy of current AHA, ARC, or ASHI CPR Certification and copies of your certificate of completion of a course meeting the requirements foradministration of local anesthesia and report card OR other state authorization and curriculum OR other state authorization and attestationsfrom former employers must be attached.I do not meet the educational/training requirements to perform this function.I have completed a board-approved course in the administration of local anesthesia as set forth in Ohio Revised Code4715.231 that was provided by an ADA accredited dental or dental hygiene program and I have successfully passedthe North East Regional Board of Dental Examiners, Inc. (NERB) Local Anesthesia Examination for Dental Hygienists orthe Western Regional Examining Board (WREB) Local Anesthesia Examination (copy of transcript from ADA accrediteddental hygiene program or certificate of completion of 29-hour course along with a copy of report card attached).ORI am authorized to administer local anesthesia in another state and I have completed a course or instruction that issubstantially equivalent to the required hours and content of the Board-approved local anesthesia course in Ohio as setforth in Ohio Revised Code 4715.231 (copy of other state authorization and a copy of curriculum attached).ORI am authorized to administer local anesthesia in another state and within the forty-eight months immediatelypreceding my application for dental hygiene licensure in Ohio, I have documented twenty-four consecutive months ofexperience in the administration of local anesthesia in the other authorizing state (copy of other state authorizationand copies of attestations from former employers attached).BOARD-APPROVED COURSE & EXAMINATIONName of Dental/Dental Hygiene Program: Location (City, State): Date of Graduation:Name of Local Anesthesia Examination:Date of Completion:STATE(S) OF LICENSUREList all states in which you have been licensed to practice and hold or have held authorization to administer local anesthesia.State: License #: Date Issued: Date Expired:EMPLOYMENT HISTORYList all places/dates of employment to indicate 24 consecutive months of experience in the administration of local anesthesia. You may makecopies of this section if additional employment is required to document sufficient experience.Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:~ 2 ~

SECTION 4ADMINISTRATION OF NITROUS OXIDE-OXYGEN (N 2 O-O 2 ) MINIMAL SEDATIONIn order to be allowed to perform this function, you MUST be currently certified to perform basic life support through the AHA, ARC, or ASHI. Acopy of current AHA, ARC, or ASHI CPR Certification and a copy of your certificate of completion of a course meeting the requirements foradministration of N 2 O-O 2 minimal sedation OR college transcript OR credential issued by another state must be attached.I do not meet the educational/training requirements to perform this function.I have completed a six-hour course in the administration (initiate, adjust, monitor, and terminate) of nitrous oxideoxygen(N 2 O-O 2 ) minimal sedation through a Permanent Sponsor which met the curriculum requirements set forth inOhio Administrative Code section 4715-9-01.2 and I have successfully passed the written examination and clinicalcompetency provided by the Permanent Sponsor (copy of certificate of completion attached)ORI have graduated on or after January 1, 2010 from an ADA accredited dental hygiene program and have completed theequivalent training within the dental hygiene curriculumORI hold a current dental hygiene license, certificate, permit, registration, or other credential issued by another state forthe administration of N 2 O-O 2 minimal sedation and the training received was substantially equivalent to the requiredhours, content and examination requirements in Ohio (see Ohio Administrative Code section 4715-9-01.2)COURSE INCLUDING EXAMINATIONName of Permanent Sponsor: Location (City, State): Date of Completion:Course Title:ADA ACCREDITED DENTAL HYGIENE PROGRAMName of ADA Accredited Dental Hygiene Program: Location (City, State): Date of Graduation:STATE OF LICENSUREList the state in which you have been licensed to practice and hold a certificate, permit, registration or other credential to administer N 2 O-O 2minimal sedation.State: License #: Date Issued:~ 3 ~

SECTION 5MONITORING OF NITROUS OXIDE-OXYGEN (N 2 O-O 2 ) MINIMAL SEDATIONIn order to be allowed to perform this function, you MUST be currently certified to perform basic life support through the AHA, ARC, or ASHI. Acopy of current AHA, ARC, or ASHI CPR Certification and a copy of your certificate of completion of a course meeting the requirements formonitoring of N 2 O-O 2 minimal sedation must be attached.I do not meet the educational/training requirements to perform this function.I have completed a six-hour course in nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation monitoring through aPermanent Sponsor which met the curriculum requirements set forth in Ohio Administrative Code section 4715-11-02.1and I have successfully passed the written examination provided by the Permanent Sponsor(copy of certificate ofcompletion attached)ORI have graduated on or after January 1, 2010 from an ADA accredited program and have completed the equivalenttraining within the curriculum (copy of dental hygiene transcript attached)COURSE INCLUDING EXAMINATIONName of Permanent Sponsor: Location (City, State): Date of Completion:Course Title:ADA ACCREDITED DENTAL HYGIENE PROGRAMName of ADA Accredited Program: Location (City, State): Date of Completion:SECTION 6EXPANDED FUNCTION DENTAL AUXILIARY (EFDA) REGISTRATIONIn order to be allowed to perform these functions, you MUST hold a current registration as an EFDA from the Board. A copy of your currentBoard-issued Expanded Funcation Dental Auxiliary Registration along with a copy of your current renewal receipt card must be attached.I do not meet the educational/training requirements to perform this function.I have completed an educational program which was a minimum of 180 hours of coursework, of which 100 hours werepreclinical and didactic, and 80 hour were clinical, through an ADA-accredited educational institution or a college oruniversity accredited by the Higher Learning Commission of the North Central Association of Colleges and Schools andI have successfully passed the standardized testing provided by the Commission on Dental Testing in Ohio, or anexamination accepted by the Board as an examination of competency to practice as an expanded function dentalauxiliary (see Ohio Revised Code 4715.39(D) and Ohio Administrative Code 4715-11-04.2).~ 4 ~

SECTION 7PRACTICE WHEN THE DENTIST IS NOT PHYSICALLY PRESENTIn order to be allowed to perform this function, you MUST be currently certified to perform basic life support through the AHA, ARC, or ASHI. Acopy of current AHA, ARC, or ASHI CPR Certification and a copy of your certificate of completion of a four (4) hour Board-approved coursemeeting the requirements for identification and prevention of potential medical emergencies must be attached.I do not meet the educational/training requirements to perform this function.I have documented two years and 3,000 hours of experience in the practice of dental hygiene and I have successfullycompleted a four-hour board-approved course in the identification and prevention of potential medical emergenciesthrough a Permanent Sponsor, subsequent to completion of my dental hygiene practice experience. (copy of certificateof completion attached)COURSEName of Permanent Sponsor: Location (City, State): Date of Completion:Course Title:EMPLOYMENT HISTORYDental hygienists must have at least two (2) years of active practice and at least 3,000 hours of experience in the practice of dental hygiene inorder to be allowed to perform this function. You may make copies of this section if additional employment is required to document sufficientexperience.Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:~ 5 ~

SECTION 8CARDIOPULMONARY RESUSCITATION (CPR) CERTIFICATEI certify that I have completed and am current in a cardiopulmonary resuscitation (CPR) course provided by theAmerican Heart Association, American Red Cross, or the American Safety and Health Institute pursuant to OhioRevised Code 4715.251 and/or Ohio Administrative Code sections 4715-9-01.1, 4715-9-01.2, and 4715-9-01.3when performing the following:• Administration of intraoral block and infiltration local anesthesia; and/or• Administration of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation; and/or• Monitoring of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation; or• practicing while the supervising dentist is not physically present, subject to the guidelines set forth inOhio Administrative Code section 4715-9-05Signature:Date:SECTION 9HEPATITIS B IMMUNIZATION/INNOCULATIONI certify that I have immunity to or immunization against the hepatitis B virus. Attach one or both of the followingsupporting documentation:• Medical documentation reflecting dates of the hepatitis B series acceptable to the Board; and/or• Surface antibody blood titer with results indicating positive, reactive or levels greater than 9.9.SECTION 10ATTESTATIONI have read the information in this form and have indicated truthfully, fully and completely those duties which Ihave been appropriately trained to provide in my scope of practice as a dental hygienist. I further certify that Ihave read carefully and understand the law and rules pertaining to the practice of dental hygiene, specificallyregarding the aforementioned permissible duties and the education, training, examination and documentationrequirements. I fully understand that falsification of any documentation may result in formal action by the OhioState Dental Board.Signature:Date:ATTENTIONTHIS FORM (PAGES 1-6), ALONG WITH ALL SUPPORTING INFORMATION ATTACHED, SHALLBE MAINTAINED IN THE FACILITY(S) WHERE THE DENTAL HYGIENIST IS WORKING AND BEMADE AVAILABLE IMMEDIATELY UPON REQUEST.DOCUMENTATION OF COMPLETION OF COURSES AND SUCCESSFUL EXAMINATION RESULTSARE YOUR PERMANENT RECORD. THE OHIO STATE DENTAL BOARD DOES NOT RECEIVENOR RETAIN COPIES OF YOUR DOCUMENTATION AND WILL NOT ISSUECERTIFICATES/LICENSES FOR THESE DUTIES/FUNCTIONS.~ 6 ~

OHIO STATE DENTAL BOARD77 South High Street, 17 th floorColumbus, Ohio 43215-6135Phone: 614-466-2580 · Fax: 614-752-8995www.dental.ohio.govPERMISSIBLE PRACTICES DOCUMENTATION FOR DENTAL ASSISTANTSTHIS FORM AND COPIES OF ALL SUPPORTING DOCUMENTATION ATTACHED MUST BE MAINTAINED IN THE DENTAL OFFICEWHERE THE DENTAL ASSISTANT IS PRACTICING THE FOLLOWING DUTIES AND OR PROCEDURES:Basic Qualified PersonnelMonitoring of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation (complete Section 3)Dental Assistant Radiographer Certificate (complete Section 4)Certified Dental AssistantPit and fissure sealants (complete Section 5)Coronal Polishing Certificate (complete Section 6)Expanded Function Dental AuxiliaryExpanded Function Dental Auxiliary Registration (complete Section 7)ALL SECTIONS OF THIS DOCUMENT MUST BE COMPLETED INDICATING THE DUTIES AND/OR FUNCTIONSYOU HAVE BEEN APPROPRIATELY TRAINED/EDUCATED TO PROVIDE. IF YOU DO NOT MEET THESPECIFIC REQUIREMENTS TO PERFORM THESE DUTIES/FUNCTIONS, CHECK THE APPROPRIATE BOX INTHAT SECTION.SECTION 1CERTIFICATE/REGISTRATION HOLDER INFORMATIONName: Radiographer Cert. #:Other Names Used: Coronal Polishing Cert. #:EFDA Registration #:SECTION 2SUPERVISING DENTIST INFORMATIONName: Ohio License #:Name of Practice:Address:City: State: Zip Code:Definition: As supervising dentist, I have evaluated the above-named dental assistant’s skills and I have made a determination that thisdental assistant has received the appropriate training and/or examination requirements for all permissible duties indicated on this form and iscompetent to perform them. I further attest that the information contained herein is true and accurate to the best of my knowledge and belief:Name (print):Date:Signature:

SECTION 3MONITORING OF NITROUS OXIDE-OXYGEN (N 2 O-O 2 ) MINIMAL SEDATIONIn order to be allowed to perform this function, you MUST be currently certified to perform basic life support through the AHA, ARC, or ASHI. Acopy of current AHA, ARC, or ASHI CPR Certification and a copy of your certificate of completion of a course meeting the requirements formonitoring of N 2 O-O 2 minimal sedation must be attached.I do not meet the educational/training requirements to perform this function.I have completed a six-hour course in nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation monitoring and I havesuccessfully passed the written examination provided by a Permanent Sponsor which met the curriculum requirementsset forth in Ohio Administrative Code section 4715-11-02.1 (attach a copy of the certificate of completion for the courseand the examination).ORI have graduated on or after January 1, 2010 from an ADA accredited program and have completed the equivalenttraining within the curriculum as set forth in Ohio Administrative Code section 4715-11-02.1(B)(2) (attach a copy of thecurriculum indicating compliance with the requirements).ORI hold a current dental auxiliary license, certificate, permit, registration, or other credential issued by another state forthe monitoring of N 2 O-O 2 minimal sedation and the training received was substantially equivalent to the required hours,content and examination requirements set forth in Ohio Administrative Code section 4715-11-02.1(B)(1) (attach a copyof the license/certificate/permit/registration or other credential from another state along with a copy of the specificeducation and examination requirements).NITROUS OXIDE-OXYGEN (N 2 O-O 2 ) MINIMAL SEDATION MONITORING COURSEName of Permanent Sponsor: Location (City, State): Date of Completion:Course Title:ADA ACCREDITED PROGRAMName of ADA Accredited Program: Location (City, State): Date of Completion:STATE CERTIFICATE/REGISTRATION/PERMITList the state in which you hold a certificate, permit, registration or other credential allowing you to monitor N 2 O-O 2 minimal sedation.State: License #: Date Issued: Date Expired:Basic Qualified Personnel must have at least two (2) years of active practice and at least 3,000 hours of experience in the practice of dentalassisting in order to be allowed to perform this function.EMPLOYMENT HISTORY FOR SECTION 3List all places/dates of employment to indicate a minimum of two (2) years of active practice and at least 3,000 hours of experience in thepractice of dental assisting. You may make copies of this section if additional employment is required to document sufficient experience.Dentists Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:Name: Phone #:Name of Practice:Address:Dates Practiced:Total Hours:City: State: Zip Code:~ 2 ~

SECTION 4DENTAL ASSISTANT RADIOGRAPHER CERTIFICATEIn order to be allowed to perform this function, you MUST have received a Dental Assistant Radiographer’s certificate from the Board. A copy ofyour Board-issued Dental Assistant Radiographer Certificate along with a copy of your current renewal receipt card must be attached.I do not meet the educational/training/Board certification requirements to perform this function.I have completed a 7-hour board-approved dental assistant radiographer initial training course, including the clinicalrequirements, through an accredited educational institution or program or a permanent sponsor of the Board (see OhioRevised Code 4715.231);ORI am a currently Certified Dental Assistant (CDA) through the Dental Assisting National Board (DANB) or a currentCertified Ohio Dental Assistant (CODA) through the Ohio Commission on Dental Assistant Certification (OCDAC) (seeOhio Revised Code 4715.231);ORI hold a current license, certificate, or other credential issued by another state that the board determines usesstandards for dental assistant radiographers that are at least equal to those established by State Dental Board rules.SECTION 5PIT AND FISSURE SEALANTSIn order to be allowed to perform this function, you MUST be a currently Certified Dental Assistant (CDA) through the Dental Assisting NationalBoard (DANB) or a currently Certified Ohio Dental Assistant (CODA) through the Ohio Commission on Dental Assistant Certification (OCDAC). Acopy of current DANB or OCDAC Certification and a copy of your certificate of completion of a course meeting the requirements for pit andfissure sealants must be attached.I do not meet the educational/training requirements to perform this function.I have completed an eight-hour course in the application of sealants consisting of at least 2 hours of didactic instructionand 6 hours of clinical instruction through an ADA-accredited educational institution or college or a program providedby a Board approved or accepted sponsor of continuing education.COURSEName of ADA Accredited Institution or College or Sponsor: Location (City, State): Date of Completion:Course Title:SECTION 6CORONAL POLISHING CERTIFICATEIn order to be allowed to perform this function, you MUST be a currently Certified Dental Assistant (CDA) through the Dental Assisting NationalBoard (DANB) or a currently Certified Ohio Dental Assistant (CODA) through the Ohio Commission on Dental Assistant Certification (OCDAC)AND you MUST have received a Coronal Polishing certificate from the Board. A copy of current DANB or OCDAC Certification and Board CoronalPolishing certificate must be attached.I do not meet the educational/training/Board certification requirements to perform this function.I have completed a 7-hour board-approved coronal polishing course (3 didactic and 4 clinical hours), including theclinical evaluation component, through an ADA-accredited educational institution or a college or university accreditedby the Higher Learning Commission of the North Central Association of Colleges and Schools and I have successfullypassed the standardized testing provided by the Dental Assisting National Board, the Ohio Commission on DentalAssistant Certification, or the educational institution wherein I successfully completed my approved training. (see OhioRevised Code 4715.39 and Ohio Administrative Code 4715-11-03.1);ORI am a currently Certified Dental Assistant (CDA) through the Dental Assisting National Board (DANB) or a currentCertified Ohio Dental Assistant (CODA) through the Ohio Commission on Dental Assistant Certification (OCDAC) and Ihold a current license, certificate, or other credential issued by another state that the board determines uses standardsthat are at least equal to those established by State Dental Board rules. (see Ohio Revised Code 4715.39 and OhioAdministrative Code 4715-11-03.1).~ 3 ~

SECTION 7EXPANDED FUNCTION DENTAL AUXILIARY REGISTRATIONIn order to be allowed to perform these functions, you MUST hold a current registration as an EFDA from the Board. A copy of your currentBoard-issued Expanded Funcation Dental Auxiliary Registration along with a copy of your current renewal receipt card must be attached.I do not meet the educational/training requirements to perform this function.I have completed an educational program which was a minimum of 180 hours of coursework, of which 100 hours werepreclinical and didactic, and 80 hour were didactic, through an ADA-accredited educational institution or a college oruniversity accredited by the Higher Learning Commission of the North Central Association of Colleges and Schools andI have successfully passed the standardized testing provided by the Commission on Dental Testing in Ohio, or anexamination accepted by the Board as an examination of competency to practice as an expanded function dentalauxiliary (see Ohio Revised Code 4715.39(D) and Ohio Administrative Code 4715-11-04.2).SECTION 8CARDIOPULMONARY RESUSCITATION (CPR) CERTIFICATEI certify that I have completed and am current in a cardiopulmonary resuscitation (CPR) course provided by theAmerican Heart Association, American Red Cross, or the American Safety and Health Institute pursuant to OhioRevised Code 4715.62 and/or Ohio Administrative Code sections 4715-11-02.1, 4715-11-02.2, and 4715-11-04.1when performing the following:• Monitoring of nitrous oxide-oxygen (N 2 O-O 2 ) minimal sedation; and/or• Expanded Function Dental Auxiliary (EFDA) duties.SECTION 9HEPATITIS B IMMUNIZATION/INNOCULATIONI certify that I have immunity to or immunization against the hepatitis B virus. Attach one or both of the followingsupporting documentation:• Medical documentation reflecting dates of the hepatitis B series acceptable to the Board; and/or• Surface antibody blood titer with results indicating positive, reactive or levels greater than 9.9.SECTION 10ATTESTATIONI have read the information in this form and have indicated truthfully, fully and completely those duties which I have beenappropriately trained to provide in my scope of practice as a dental assistant. I further certify that I have read carefully andunderstand the law and rules pertaining to the practice of dental assisting, specifically regarding the aforementioned permissibleduties and the education, training, examination and documentation requirements. I fully understand that falsification of anydocumentation may result in formal action by the Ohio State Dental Board.Signature:Date:ATTENTIONTHIS FORM (PAGES 1-4), ALONG WITH COPIES OF ALL SUPPORTING DOCUMENTATIONATTACHED, SHALL BE MAINTAINED IN ALL FACILITY(S) WHERE THE DENTAL ASSISTANT ISWORKING AND BE MADE AVAILABLE IMMEDIATELY UPON REQUEST.~ 4 ~

Ohio State Dental BoardInfection Control Evaluation FormName:Date:Address:Practice name: Phone #:Investigator: ________________________ Case #:____________ County #:_____A) Heat Sterilization: Yes No Steam # ___ Chemical # ___ Dry #___B) Weekly Biological Testing: Yes No If No – How often?Independent Entity ___________________ In-Office ________________ Control: Yes NoC) Chemical Sterilization: Yes N/A What BrandD) Disposables not disposed of:Heat SterilizedE) High speed handpieces: # ______ Yes NoContra-Angles Yes No N/ANose Cones/Hyg. Handpieces Yes No N/ABurs Yes No N/AEndodontic Files/Reamers Yes No N/AHand Instruments Yes No N/AOrthodontic Instruments Yes No N/AProphy Angles Yes No N/AAir/Water Syringe Tips Yes No N/AMetal Impression Trays Yes No N/AUltra Sonic Scalers Yes No N/AIntra-Oral Radiography Equip Yes No N/AOtherF) Wrap utilized (when needed): Yes No N/A Changed Between Pts: Yes NoG) Surface Disinfectant Used: Yes No What BrandUsed According to Manf. Inst. Yes NoH) Sharps Container(Approved): Yes No If No – What kind of container? ___________I) Gloves: Yes No If No – Who?Masks (when needed): Yes No If No – Who?Eye Protection w/Side Shieldsand/or Chin Length Face Shield Yes No If No – Who?

DentistsHBVHBVWaiver License #PostedCSGAHygienistsHBVHBVWaiver License #LocalAnes.N 2 O(I)N 2 O(M)PRAC.UNSUPERvisedEFDAAssistants/Other DHCWsHBVHBVWaiverRad.Certificate #CDASealantsN 2 O(M)CPEFDADentist SignaturePerson assisting with evalutationPrint NameFor Official Use OnlyDate of Last ICE:Send Certificate No Certificate Verbal Warning Warning Letter Enforcement Prior IC Violations