Copyright © 2010 Florida DOH

Candidate Information Booklet

June 2010

Florida Board of Dentistry

Dental Hygiene Clinical Examination

Prepared and Administered by

Florida Department of Health&

North East Regional Board of Dental Examiners, Inc

Copyright © 2010 Florida DOHRevised 03/10

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THIS CANDIDATE INFORMATION BOOKLET (CIB)

CONTAINS PROCEDURAL INFORMATION TO ASSIST YOU IN

TAKING THIS EXAMINATION.

PLEASE REVIEW CAREFULLY.

MEMORANDUM

DATE: March 1, 2010

TO: Licensure Candidates

FROM: Testing Services

SUBJECT: Candidate Information Booklet

FOR INFORMATION ONLY

The Testing Services Unit is responsible for Florida’s dental and dental hygiene licensure examinations. An area of continual focus relates to this Candidate Information Booklet (CIB).

This CIB is intended to provide candidates all the examination administration information that is necessary for them to be successful. It has evolved over the years based in large part to candidate feedback and your input is now specifically sought to further improve this booklet.

Review the provided CIB for readability. Note areas that are confusing, redundant or appear inaccurate as well as areas that are appropriate and useful.

Page Number Issue to be Fixed / Adjusted / Removed Candidate Recommendation

Thank you in advance for your time and consideration. The Department is committed to continually improving the services it provides and we are confident your efforts will present long term benefits.

This sheet will be This sheet will be collected at the collected at the

Mandatory Mandatory Candidate Candidate

OrientationOrientation

LICENSURE EXAMINATION CONTENT OVERVIEW..................................................................................................................................6

WRITTEN PORTION - LAWS & RULES EXAMINATION................................................................................................6CLINICAL PORTION -CLINICAL EXAMINATION...........................................................................................................6

OVERVIEW OF THE FLORIDA DENTAL HYGIENE EXAMINATION.......................................................................................................7

COMPUTER SIMULATED PART OF THE CLINICAL EXAMINATION.................................................................................7STANDARDS FOR THE COMPUTER SIMULATED CLINICAL EXAMINATION (CSE-FL)...................................................8PATIENT TREATMENT PART OF THE CLINICAL EXAMINATION....................................................................................9

ADMINISTRATIVE POLICIES...............................................................................................................................................................10

LIABILITY.................................................................................................................................................................10ADMISSION TO THE EXAMINATION..........................................................................................................................10CHANGE OF ADDRESS..............................................................................................................................................11CHANGE OR CORRECTION OF NAME.......................................................................................................................11LATE ARRIVALS.......................................................................................................................................................11RULES FOR THE EXAMINATION...............................................................................................................................11

STANDARDS OF CONDUCT.........................................................................................................................................................13

IMPROPER CONDUCT WARNING...............................................................................................................................13CONDUCT STANDARDS.............................................................................................................................................13

PATIENT TREATMENT TIME SCHEDULE..............................................................................................................................................15

CANDIDATE ORIENTATION........................................................................................................................................15CLINICAL EXAMINATION ADMINISTRATION..............................................................................................................15

THE CLINICAL EXAMINATION...........................................................................................................................................................16

ORIENTATION...........................................................................................................................................................16PATIENT TREATMENT CLINICAL EXAMINATION........................................................................................................16TIME MANAGEMENT.................................................................................................................................................16PROCUREMENT OF PATIENTS...................................................................................................................................17STANDARDS FOR THE PATIENT TREATMENT CLINICAL EXAMINATION.....................................................................17

Auxiliary personnel...................................................................................................................................18 Interpreters.................................................................................................................................................18

APPAREL...................................................................................................................................................................19ARRIVING AT THE EXAMINATION SITE...................................................................................................................19ADMISSION TO THE CLINIC......................................................................................................................................19

MEDICAL CLEARANCE................................................................................................................................................................20

MEDICAL HISTORY...................................................................................................................................................20 Blood Pressure...........................................................................................................................................21

INFECTION CONTROL PROCEDURES.....................................................................................................................................22

STERILIZATION AND DISINFECTIONS.........................................................................................................................22

GENERAL REQUIREMENTS..................................................................................................................................................................24

PATIENT SELECTION AND ELIGIBILITY:....................................................................................................................24RADIOGRAPHS..........................................................................................................................................................24TREATMENT SELECTION...........................................................................................................................................25CALCULUS DETECTION.............................................................................................................................................26POCKET DEPTH MEASUREMENTS.............................................................................................................................26SCALING...................................................................................................................................................................26POLISHING................................................................................................................................................................26

PATIENT CRITERIA:............................................................................................................................................................................27

Patient Disqualification:......................................................................................................................................27

Florida CIB Dental Hygiene 06_20104

PATIENT TREATMENT PROCEDURES....................................................................................................................................28

FORMS...............................................................................................................................................................................................32

EXAMINATION SCORING............................................................................................................................................................34

Computer Simulated Part of the Clinical Examination (CSE-FL) - 100 Points..................................................34Patient Treatment Part of the Clinical Examination - 100 Points.......................................................................34Grading Competency Levels...............................................................................................................................35Points or Penalties...............................................................................................................................................35Penalty Deductions..............................................................................................................................................36

SCORING INFORMATION AND GRADE NOTIFICATION......................................................................................................................38

SCORING PROCEDURES.............................................................................................................................................38NOTIFICATION OF RESULTS.....................................................................................................................................38

EXAMINATION CRITERIA..............................................................................................................................................................39

PATIENT SELECTION.................................................................................................................................................39TISSUE AND TREATMENT MANAGEMENT.................................................................................................................41

POST-EXAMINATION PROCEDURES....................................................................................................................................................42

PASSING CANDIDATES..............................................................................................................................................42FAILING CANDIDATES...............................................................................................................................................42REEXAMINATION INFORMATION...............................................................................................................................42POST- EXAMINATION REVIEW PROCESS...................................................................................................................43ELECTION OF HEARING RIGHTS...............................................................................................................................43

EVALUATION – GENERAL RULES............................................................................................................................................45

EXAMINATION EQUIPMENT, PROCEUDRES AND PROCESSES:........................................................................................46

Presenting Your Patient for CASE ACCEPTANCE:.........................................................................................46Clinic Monitor Evaluation and Operatory Set-Up:.............................................................................................47Pre-Treatment and Post-Treatment Evaluation Procedures:...............................................................................47Presenting Your Patient for PRE-TREATMENT and POST-TREATMENT GRADING:...............................48Examiner Grading and Operatory Clean-Up:......................................................................................................48

EQUIPMENT AND SUPPLIES................................................................................................................................................................49

Required Materials:.............................................................................................................................................49Total materials needed:.......................................................................................................................................49Instruments for Candidate Use During Treatment:.............................................................................................51Optional Materials:..............................................................................................................................................51Prohibited:...........................................................................................................................................................52

APPENDICES.........................................................................................................................................................................................53

ULTRASONIC INSTRUMENTS......................................................................................................................................54HANDPIECE CONNECTION DIAGRAMS...........................................................................................................54ULTRASONIC SYSTEM CONNECTION......................................................................................................................55PATIENT DISCLOSURE STATEMENT AND EXPRESS ASSUMPTION OF RISK........................................64POST-EXAMINATION REVIEW REQUEST FORM..........................................................................................65ADDRESS CHANGE FORM.................................................................................................................................67Contact Information..................................................................................................................................................69


STATEMENT OF NONDISCRIMINATORY POLICY

The Department of Health does not discriminate among candidates on the basis ofage, sex, race, religion, national origin, handicap, or marital status.

This edition of the Candidate Information Booklet supersedes all previous editions.

PLEASE SAVE THIS DOCUMENT FOR FUTURE REFERENCE

Please read this manual in detail prior to attending the candidate orientation

AND

bring it with you to the orientation and examination.

It should also be maintained for future reference.


Licensure Examination Content Overview

o The Board of Dentistry specifies that the Dental Hygiene Licensure Examination administered by the Department of Health shall consist of two portions. One portion of the examination shall consist of a written examination and one portion of the examination shall be a clinical examination.

Written Portion - Laws & Rules Examination

The Laws & Rules Examination is a 40 question computer-based examination administered by the Department’s contracted vendor, Prometric. For information regarding all aspects of this examination, please refer to the Computer Based Testing (CBT) Candidate Information Booklet (CIB) for this examination. The CBT Laws & Rules CIB can be found on the Testing Services website (contact information located on the last page of this booklet). The applicable laws and rules and their on-line locations are:

o Chapter 466, Florida Statutes (Florida Dental Practice Act)

http://www.flsenate.gov/statutes/index.cfm

o Chapter 64B5, Florida Administrative Code (Board Rules)

http://fac.dos.state.fl.us/

Clinical Portion -Clinical Examination

The Clinical Examination consists of two parts, each must be passed with a 75%:

o Computer Simulated Examination (CSE-FL)

o Patient Treatment

The Patient Treatment part of the Clinical Examination requires a candidate to perform a partial prophylaxis, root planing (biofilm removal), coronal polishing, and probing procedures on selected teeth.

The Patient Treatment part of the Clinical Examination process will take approximately four hours.


http://fac.dos.state.fl.us/

Overview of the Florida Dental hygiene Examination

CONTENT and FORMAT

Computer simulated part of the clinical examination

CONTENT FORMAT

Health Assessmento Medical emergencieso Therapeuticso Disease prevention and health promotion

Oral Condition Evaluationo Normal anatomyo Soft tissue, bone and tooth abnormalitieso Periodontal conditions

Radiography Interpretations Infection Control

Simulated Patients Presented on a Computer

COMPUTER SIMULATED CLINICAL EXAMINATION (CSE- FL)

The CSE-FL is a computer simulated patient clinical performance examination that utilizes a multiple-choice format to indicate examinees’ responses. It is an integral component of the Florida Clinical Examination in Dental Hygiene and differs from the National Board Dental Hygiene Examination, which is a comprehensive achievement examination in the theory of dental hygiene. The National Board is a prelude to clinical performance examinations that may be conducted on patients as well as on simulated patients such as the CSE-FL.

The CSE-FL is designed to assess clinical issues in a standardized manner.

Simulations of actual patients are utilized through computer-enhanced photographs, radiographs, optical images of study and working models, laboratory data and other clinical digitized reproductions.

There are 100 items in the CSE-FL. Pilot items may be added but do not affect the score. Appropriate additional time is provided for these unscored pilot items.

The candidate may skip or mark items to be considered later. Once the CSE-FL is completed and the candidate locks out of the Examination, she/he will not be able to return to the Examination again. The time indicated on the computer screen is the amount of time for the Examination. There is no specific time limitation for each item.

The Computer Simulated Clinical Examination is administered by Prometric at their testing centers by appointment after eligibility authorization is granted to the examinee by the Florida Board of Dentistry, Florida Department of Health and the NERB. Approximately two (2) hours are allotted for this examination. No study materials may be brought to the center and recording of


test items is prohibited. Violation of these rules constitutes a violation of the Standards for the Computer Simulated Clinical Examination and may result in failure of the examination.

A brochure that is sent by the NERB with the authorization to take the CSE-FL at a Prometric Testing Center contains valuable information on appointment scheduling, arriving at the center and material required. The Rules for conduct of the examination as established by Prometric must be followed.

TEST CONSTRUCTION

The test construction maximizes input from across the United States and avoids emphasis on any concept or procedure that may have limited applicability. The Examination Committee, which is responsible for test development, consists of equal numbers of examiners and educators. In addition, special consultants review the examination before it is finalized. Because of the NERB’s broad-based approach to test development, no single textbook or publication can be used as the sole reference. Every effort is made to ensure that the examination is based on concepts taught and accepted by educational institutions accredited by the American Dental Association or Canadian Commissions on Dental Accreditation. Any current textbook relevant to the subject matter of the examination utilized in such institutions should be suitable as a study reference.

For more information on the CSE-FL and sample questions, please refer to the NERB website (www.nerb.org), click on the Prometric Demo menu choice on the left, and follow the instructions to

download the information on the CSCE.

Standards for the computer simulated clinical examination (CSE-FL)

o Extraneous materials. Only those materials distributed or authorized by Prometric may be brought to the Prometric Center. Use of unauthorized materials will result in failure of the entire Examination. No textbooks or study materials are permitted at the Prometric Testing Center at any time.

o Time schedule. A specific total amount of time is allowed for the Computer Simulated Clinical Examination. Once a candidate has completed and locked out of the CSE-FL, the candidate may not re-enter the CSE-FL.

o Timely arrival. The date and appointment schedule established by Prometric must be adhered to as confirmed. Failure to do so will result in forfeiture of the examination fee.

o Behavior at the Prometric Testing Center. Unseemly behavior of the candidate or improper behavior toward personnel at the Prometric Testing Center will result in failure of the CSE-FL and forfeiture of the examination fee.

o Examination security. Security measures established by the NERB and Prometric must be followed. Failure to do so may result in failure of the Examination.


OVERVIEW OF THE FLORIDA DENTAL HYGIENE EXAMINATIONCONTENT and FORMAT

Patient treatment part of the clinical examination

CONTENT FORMAT

Case Acceptance o Patient requirements o Pocket depth qualificationo Pocket depth measurement/candidate

Treatment Evaluation o Subgingival calculus detection and removalo Plaque/Stain/Supragingival calculus removalo Pocket depth measurement/examinero Patient management

Performed on a Patient


Administrative Policies

Liability

It is expressly understood by each candidate that the State of Florida, the North East Regional Board of Dental Examiners, Inc. The Department of Health, and/or the Department’s staff hereby assume absolutely no liability of any nature whatsoever for any items of the candidate’s personal property which may have been brought to, left at, or left outside the examination site. It is further understood that the candidate’s admission to the examination shall hereby constitute the candidate’s full knowledge and complete waiver of any and all such claims against the State of Florida, the North East Regional Board of Dental Examiners, Inc, the Department of Health, and/or the Department’s staff.

Admission To The Examination

Admission packets will contain a white admission slip, Candidate Release of Liability Form, examination schedule, and the time and location of the Candidate Orientation.

IF YOU HAVE APPLIED FOR THE EXAMINATION AND HAVE NOT RECEIVED AN ADMISSION PACKET FROM the North East Regional Board of Dental Examiners, Inc. (NERB), the examination administrator for the Florida Department of Health, Testing Services, TWO WEEKS PRIOR TO THE EXAMINATION PLEASE CONTACT NERB IMMEDIATELY (contact information located on the last page of this booklet).

You and your patient must report to the examination site a minimum of thirty (30) minutes prior to your Reporting Time indicated on your admission slip/examination schedule.

YOU MUST PRESENT YOUR WHITE ADMISSION SLIP, CANDIDATE RELEASE OF LIABILITY FORM AND BE PREPARED TO SHOW YOUR CURRENT IDENTIFICATION TO GAIN ENTRY TO THE CANDIDATE ORIENTATION. Candidates must provide one of the following government issued forms of identification containing your picture and signature:

Government-issued driver’s license;

State-issued identification card;

Government-issued passport or Resident Card;

Military identification card;

Student or employment I.D. cards and photograph/photocopies are NOT acceptable.

YOU MUST WEAR THE OFFICIAL ID PROVIDED AT THE CANDIDATE ORIENTATION AND PRESENT YOUR WHITE ADMISSION SLIP, PATIENT CONSENT, DISCLOSURE AND RELEASE OF LIABILITY FORMS TO GAIN ENTRY TO THE EXAMINATION CLINICS.


Change Of Address

All candidates will be given an opportunity to file a change of address at the examination site. If an address change occurs after your examination, please notify the Board Office by completing the change of address form provided in the Appendices.

Change Or Correction Of Name

If you have a name change or name correction, please send a copy of notarized legal documentation to the Board Office immediately (contact information is located on the last page of this booklet).

Late Arrivals

Candidates who arrive late for the Candidate Orientation or their Clinic Session will NOT be permitted to sit for the examination.

If you arrive at the clinics after the examination instructions have started, you are late and will not be permitted into the clinics. If you are late, you will need to reapply to the Board and pay the required application and examination fees in order to be scheduled for the next available examination.

You will not be admitted into the clinics without a patient. Therefore, if your patient is late, you will be considered late and will not be permitted to take the examination.

Rules For The Examination

No examination materials, documents, or memoranda of any kind are to be taken from the examination room.

Listen carefully to the instructions given by the Clinic Monitors and read all directions thoroughly. Clinic Monitors will do their best to answer any questions you may have.

Proctors are NOT qualified or authorized to answer questions concerning the examination.

ALL COMMUNICATION MUST BE IN ENGLISH. You may communicate only with your patient in another language.

You are prohibited from collaborating with other candidates during any part of the examination.

You must have permission from a Clinic Monitor before you may communicate with any other candidate for any reason.

You are prohibited from using ANY study or reference materials during the examination.

You are encouraged to bring this CIB to the examination. Notes may be handwritten in the CIB.

Patients considered as “alternate patients” may be shared between candidates.

STERILE AND SANITARY TECHNIQUES, EQUIPMENT, AND SUPPLIES MUST BE USED AT ALL TIMES DURING THE CLINICAL EXAMINATION.

You must remove your patient’s napkin anytime the patient leaves the clinic for any reason other than going to the Grading Clinic (e.g. to go to the restroom).

You and your patient must wear your identification badges at all times during the clinical examination.

The patient’s ID badge should be pinned to their Right shoulder.


Only you and your patient will be allowed in the clinic areas at any time. All others, including alternate patients, will be required to remain in the first floor lobby or away from the examination site.

You must have permission from a Clinic Monitor and sign in and out at the Proctor desk to leave the examination clinic. You will not be allowed additional time to make up for time lost.

The Clinic Monitors are the Department’s designated agents in maintaining a secure and proper examination administration and examination site.


STANDARDS OF CONDUCT

Improper Conduct Warning

DEVIATION FROM THESE GUIDELINES MAY RESULT IN REMOVAL FROM THE EXAMINATION SITE, REPORT TO THE BOARD OF DENTISTRY, AND/OR DENIAL OF LICENSURE.

Candidates are expected to act professionally.

Rule 64B-1.004 Florida Administrative Code states the following:

(1) The examination administrator and proctors are the department’s designated agents in maintaining a secure and proper examination administration. Failure to comply with the written and/or oral instructions provided by the department’s designated agents shall result in the removal of the examinee from the examination site.(2) Any individual found by the department or any board within the department to have engaged in conduct which subverts or attempts to subvert the examination process shall have his or her scores on the examination withheld and/or declared invalid, be disqualified from the practice of the profession, and/or be subject to the imposition of other appropriate sanctions by the applicable board or department, when there is no board.(3) Conduct, which subverts or attempts to subvert the examination process includes:

(a) Conduct which violates the security of the examination materials, such as removing from the examination site any of the examination materials; reproducing or reconstructing any portion of the licensure examination; aiding by any means in the reproduction or reconstruction of any portion of the licensure examination; selling, distributing, buying, receiving or having unauthorized possession of any portion of a future or current licensure examination.

(b) Conduct which violates the standard of test administration, such as communicating with any other examinee during the administration of the examination; copying answers from another examinee or permitting one’s answers to be copied by another examinee during the administration of the examination; having in one’s possession during the administration of the examination any book, notes, written or printed materials or data of any kind, other than the examination materials distributed or specifically listed as approved materials for the examination in the information provided to the examinee in advance of the examination date by the department and/or the contracted vendor of the examination.

(c) Conduct which violates the credentialing process, such as falsifying information required for admission to the examination; impersonating an examinee or having an impersonator take the licensure examination on one’s own behalf.(4) Any violation of the conduct rules or other irregularities will be documented in writing by the department’s agent(s) and the documentation of the violation or irregularity will be presented to the appropriate board or departmental unit for consideration and action.

As stated in Chapter 456.018, Florida Statutes:

In addition to, or in lieu of, any other discipline imposed pursuant to Florida Statute 456.072 the act of reproducing, copying or removing any examination administered by the department whether said examination is reproduced or copied in part or in whole and by any means, constitutes a felony of the third degree, punishable as provided in Florida Statutes 775.082, 775.083, or 775.084.

Conduct Standards

The Florida Board of Dentistry, Department of Health and the North East Regional Board of Dental Examiners (NERB) strive to evaluate the candidate’s clinical judgment and skills in a fair manner. In addition, conduct, decorum and professional demeanor are evaluated. The candidate is required to adhere to the rules, regulations and Standards of Conduct for the Clinical Examination in Dental Hygiene as follows:


Personal and professional conduct. Any substantiated evidence of collusion, dishonesty, use of unauthorized assistance or intentional misrepresentation during registration or during the course of the examinations or failure of the candidate to carry out a directive of the Chief Assistant Examination Supervisor or Examination Administrator shall automatically result in failure of both parts of the Clinical Examination. Candidates must behave in an ethical and proper manner. Patients shall be treated with proper concern for their safety and comfort. Improper or unethical behavior is cause for dismissal and will result in failure of the examination. Additionally, an Irregularity Report will be filed with the Florida Board of Dentistry subjecting the candidate to discipline or restriction.

Termination of the examination. The Assistant Examination Supervisor and the NERB reserve the right to terminate or delay the examination at any time if that action becomes necessary to safeguard the health, safety or comfort of the patient; or if the candidate or examiners are threatened in any manner; or if other interfering events occur which are not under the control of the NERB.

Completion of the examination. Both parts of the Florida Clinical Examination in Dental Hygiene must be completed within the specified time frame in order to be considered for Florida licensure. Examination procedures performed outside the assigned time schedule will be cause for the examination to be considered incomplete and will result in failure. If all specified materials and required documentation are not turned in at the end of an examination, the examination is considered incomplete and will result in failure.

Misappropriation and/or damage of equipment. No equipment, instruments, or materials shall be removed from the examination site without written permission of the owner. Willful or careless damage of dental equipment may result in failure. All repair or replacement costs resulting from damage during the examination will be charged to the candidate and must be paid before the candidate’s examination results will be released.

Submission of examination records. All required records and radiographs must be turned in at the Monitor’s Table before the examination is considered complete. If all required documentation is not turned in at the end of the examination, the examination is considered incomplete and will result in the failure of all examinations involved.

Assigned procedures. Only the treatment and/or procedures assigned may be performed. All surfaces of the teeth in the primary quadrant and any additional teeth selected in an alternate quadrant must be scaled and polished. Performing other treatment or procedures may result in failure of the examination.

Guidelines. Failure to follow the published standards and guidelines; the use of electronic recording devices by the candidate, or a patient during any part of the examination; or the taking of photographs during the evaluation or treatment procedures is a violation of Guidelines and may result in failure of the Clinical Examination in Dental Hygiene. However, intra-oral photographs may be taken by examiners or school personnel authorized by the Examination Administrator during the course of the examination for purposes of future standardization and calibration.

Electronic equipment. The use of phones, IPODs, computers, Blackberries, radios (including walkie-talkies with or without earphones) and any other electronic equipment by candidates or patients is not permitted on the clinic floor during the examination and any such use will be considered unprofessional conduct and may result in confiscation of the equipment and dismissal from the examination.


PATIENT TREATMENT TIME SCHEDULE

Patient Treatment part of the Clinical Examinations – Four Hours

The total time for administration of the Patient Treatment part of the Clinical Examination is four hours. During this time, the candidate must complete required paperwork, take and record the patient’s blood pressure, submit the patient for the Case Acceptance evaluation, measure the sulcus/pockets depths of the assigned teeth, present the patient for Pre-Treatment evaluation, carry out the assigned treatment and present the patient for evaluation of treatment. The time allotted for Case Acceptance, Pre-Treatment evaluation and actual patient treatment is 180 minutes of which the time for actual patient treatment is ninety (90) minutes or one and one-half (1 ½ ) hours.

Orientation (mandatory attendance)

Group A. Patient Treatment Clinical Examination

On the day prior to the clinical examination

7:30 AM to 11:30 AM

Orientation (mandatory attendance)

Group B. Patient Treatment Clinical Examination

On the day prior to the clinical examination

1:00 PM to 5:00 PM

Each candidate must adhere to the published time schedule.

Candidate orientation

Candidates taking the Patient Treatment part of the Clinical Examination must be present during the entire Candidate Orientation held the day prior to the start of the clinical examinations. During orientation candidates will receive specific instruction and distribution of examination materials by the Examination Administrator. The time and location of the Candidate Orientation will be provided by mail. The candidate’s White Admission Slip and Candidate Release of Liability Form must be presented as well as the required one (1) form of photo identification with the candidate’s signature or the candidate will not be admitted to orientation.

Clinical examination administration

Candidates who do not have the required forms as listed will not be admitted to the Clinical Examination. White Admission Slip Patient Consent Form Patient Disclosure Form Patient Release of Liability Form Patient Health History Form

o “Yes” answered circled in red Candidate identification obtained from the Candidate Orientation.


The Clinical Examination

Orientation

Attendance to Candidate Orientation is MANDATORY. There will be no exceptions. If you are late or miss orientation, you will NOT be allowed to take the examination.

You must report to orientation at the specified report time for candidate check-in.

Admission packets will contain the time and location of orientation.

You must present your white admission slip and the required photo ID to attend orientation.

You must present your completed Candidate Release of Liability Form (blue).

NOTE: Check-in for orientation may take approximately one hour. Therefore, be prepared for the orientation to take up to three hours.

Pertinent information about the examination will be distributed at orientation:

o Scheduling of the examination

o Changes in Board rules related to the examination

o A question and answer period

NOTE: Only candidates who are taking the examination will be allowed to attend orientation. No family members, patients or anyone not taking the examination will be allowed entry.

Patient treatment clinical examination

The examination must be taken at the assigned time, beginning at either 7:30 AM or 1:00 PM depending on the group assignment. Patients must be ready for patient assessment at those times. Candidates should be present thirty (30) minutes prior to their Reporting Time in the lobby of the examination site. All treatment must stop for the morning session at the candidate’s Finish Time and no later than 11:30 AM and at the candidate’s Finish Time and no later than 5:00 PM for the afternoon session. Candidates who are not participating in the Patient Treatment part of the Clinical Examination must leave the clinic when their time for the Clinical Examination has expired.

Time management

Candidates will be given no more than 180 minutes to seat a patient, present the patient for acceptance and complete the Treatment Phase of the patient based part of the examination. Candidates should be aware that the time allowed for patient treatment includes the time during which the patient(s) is in the Grading Clinic for Pre-Treatment evaluation. Expect that these times will vary and that patients may not return in the exact order at which they signed-out. A minimum of 30 minutes must be available to the candidate during the four (4) hour examination time for treatment of the patient. If there is less that 60 minutes remaining in the allotted four (4) hour session time and the patient has not been submitted for Pre-Treatment evaluation, the candidate’s examination will be stopped for the safety of the patient.


Procurement Of Patients

REQUIRED: You are entirely responsible for the acquisition of patient(s) necessary for this examination.

You must bring your own patients for this examination. Preparations and arrangements should be made ahead of time for qualified patients.

Facilities at the examination site are NOT available for patient procurement.

WARNING: Patient brokers may be brokering patients to candidates for a fee at the examination site. This is illegal. The Florida Board of Dentistry considers the brokering of patients a breach of s. 456.054, F.S., as well as one or more of the following grounds for discipline: s. 466.028(1) (i), (m), (t) and (u), F.S. The brokering of patients is unethical, deceitful, and fraudulent. Candidates brokering patients or buying patients from a broker will be prosecuted to the full authority of the Board and may result in withholding of the license, an administrative fine of $10,000.00 per count, and other penalties imposed by the Board.

CANDIDATES WILL NOT BE ALLOWED INTO THE EXAMINATION CLINICS WITHOUT A PATIENT. Patients should be instructed to meet at the waiting area approximately one-half hour before admission for the Clinical Examination. Be sure to inform your patient(s) that the examination process will last at least five hours.

Standards for the patient treatment clinical examination

Management of significant history and pathosis. The candidate shall accurately complete the appropriate medical history form and select the teeth and surfaces that meet the criteria as required for each selected patient. Misinformation or missing information that would endanger the patient, candidate, or Examiners is considered cause for appropriate action including dismissal from the examination.

o Patients who are currently or have in the past taken bisphosphonate medications, either by IV or orally, have a latex allergy, active herpetic lesions, are pregnant, blood pressure exceeding guidelines or any other conditions listed in the Patient Disqualification section of this booklet are NOT permitted to take part in this examination.

Assigned operatories. Working in areas not authorized by the NERB will result in failure of the examination.

Professional attitude/demeanor/patient management. The candidate must behave in an ethical and proper manner. Patients shall be treated with proper concern for their safety and comfort. Failure to follow directions and instructions from Examiners will be considered unprofessional conduct. Improper behavior is cause for dismissal from the examination and will result in failure of the examination. Additionally, the candidate shall be referred to the Florida Board of Dentistry for further action.

Infection control standards. Candidates must follow the recommended infection control procedures recommended by the Centers for Disease Control and Prevention including setting up prior to the examination and cleaning up after the examination has ended. Violation of the Infection Control Standards may result in failure of the examination.


Treatment selection. Treatment selections that fulfill examination requirements published for each procedure must be met. Failure to do so will result in denial of the candidate to take the examination. Candidates must make treatment selection decisions independently (without the help of faculty and/or colleagues).

Tissue management. There shall be no unwarranted damage to either hard or soft tissue. Incompetent or careless management of tissue will result in a score reduction.

Equipment failure. In case of equipment failure, the Clinic Monitor must be notified immediately and he/she will request that maintenance personnel assess and correct the specific situation. Extension of examination time may be granted for maintenance and repair of equipment (chair, light, and dental unit) that exceeds five (5) minutes for equipment that is the responsibility of and provided by the school. Additional time will not be granted for breakdown of a candidate’s personal equipment.

Topical anesthetic. The candidate is responsible for ensuring that the appropriate topical anesthetic is correctly recorded on the Progress Form. (Oraqix® is considered a topical anesthetic.) Local injectable anesthesia, inhalation or intravenous analgesia, or general anesthetics are NOT permitted for the examination. Violation of this Standard will result in failure of the affected examination.

Auxiliary personnel. Assistants are NOT permitted for this examination.

Interpreters. For patients who do not speak English or are hearing impaired (and their hearing loss cannot be corrected) an interpreter must be arranged for by the candidate and is the responsibility of the candidate. (This is particularly important when the patient has a history of medical problems or is on medications.)

o The candidate MUST contact the NERB Central Office prior to the examination if an interpreter is going to be utilized.

o Faculty members, dentists and dental hygienists (licensed or unlicensed), third or fourth year dental students, and final year dental hygiene students may not act as an interpreter during the Patient Treatment Clinical Examination.

o If an interpreter is to be used candidates are responsible for the registration of the interpreter and for the conduct of the interpreter during the examination. The candidate must notify the Chief Assistant Examination Supervisor (AES) following Candidate Orientation and the Chief AES will provide the needed Interpreter Disclosure Statement and Interpreter ID Form. The candidate must bring two separate 2” x 2” passport quality photos of the interpreter, one to be attached to the top of the Interpreter Disclosure Statement and one attached to the bottom of the form which serves as the interpreter’s ID. During the clinical examination, the interpreter must wear a photo identifying badge provided by the NERB at all times when on the clinic floor.


Apparel

PLEASE DRESS COMFORTABLY BUT APPROPRIATELY (IN CONFORMANCE WITH CDC REQUIREMENTS) FOR THE EXAMINATION. The examination clinics are usually climate controlled. However, it is not always possible to maintain a temperature suitable to each candidate, and from time to time there are maintenance problems beyond the Department’s control. It is suggested that you bring a sweater or jacket in case the temperature is cooler or warmer than your individual preference. Candidates should also take into consideration the comfort of their patient and advise them to dress accordingly as well.

Arriving At The Examination Site

You MUST evaluate your patient(s) before arriving at the examination site.

NOTE: Clinics will not be available prior to the start of the examination for the evaluation of patients. You will be able to evaluate your patient (or alternate patients in the event YOU disqualify your initial patient) in your operatory PRIOR to submission for the examination to the Clinic Monitor.

PROHIBITED: Patients CANNOT be evaluated in the lobby area.

Admission packets will contain information about each candidate’s scheduled examination time.

Candidates and patients should be at the examination site 30 minutes before your Reporting Time.

Patients MUST complete and sign the Patient’s Health History, Patient Consent, Patient Disclosure Form and Release of Liability Form. (See the “Forms Used During the Examination” section of this booklet for more information on these forms.)

Complete the “candidate number” and “examination date” portions on all of these forms.

Initial the Patient’s Health History to acknowledge that you have reviewed it.

Admission To The Clinic

Present your white admission slip, Patient Consent, Disclosure and Patient Release of Liability Forms to be admitted to the examination clinic.

PROHIBITED: Candidates shall not enter the dental clinics or laboratories while the college is in session or at any time before the examination. Examination or university staff will secure the names of any candidates entering the facilities prior to the assigned examination time. Candidates who violate this policy will be reported to the Florida Board of Dentistry.

Examination staff will escort you and your patient into the examination clinic at your scheduled time.

NOTE: You will not be allowed into the examination clinic without a patient.

Go to the operatory which is labeled with your candidate ID number.

Seat your patient.

Wait for instructions from the Clinic Monitor or examination proctors.


MEDICAL CLEARANCE

Medical history is to be recorded on the Medical History Form and, when necessary, a written medical clearance by a licensed physician is to be obtained. Examples of the need for medical clearance include but are not limited to history of: myocardial infarction, infective endocarditis, congenital heart disease, cardiac surgery, coronary arteriosclerosis, tuberculosis, chemo or radiotherapy, hypertension (uncontrolled), diabetes mellitus, blood disorders and infectious diseases. Any “Yes” answer on the Medical History could require a Medical Clearance if the condition could affect the patient’s suitability for elective dental treatment during the examination.

o Medical clearances must include: A clearly legible and signed statement from a licensed physician written within 30 days

of the examination on official physician letterhead stationery, A positive statement of how the patient should be managed, The physician’s name, address and phone number clearly legible, A telephone number where the physician may be reached on the day of the examination

if a question arises regarding the patient’s health.

MEDICAL HISTORY: A Medical History Form must be completed independently (without help of faculty or colleagues) prior to the examination for each clinical patient. This form may be completed prior to the examination date, however, a medical history that reflects the patient’s current health must be presented to the examiners at the time of patient check-in. All positive responses must be explored by the candidate with the patient and adequately explained on the Medical History Form.

A screening blood pressure reading should be taken when the patient is selected and MUST be retaken and recorded on the day of the examination. In addition, on the day of the examination the candidate must update all medications or supplements taken within the last 24 hours. Patients requiring antibiotic pre-medication must have this documented on the Progress Form as well as on the Medical History.

If the Medical History indicates conditions requiring an alteration in treatment or a need to consult the patient’s physician, the candidate must obtain the necessary written medical clearance before the patient will be accepted. A person with a history of an infectious or communicable disease, or a serious systemic condition, will not be allowed to sit as a patient during the examination unless a current statement from a physician is submitted certifying that the patient and proposed treatment will not pose an undue public health risk or a risk to the patient. (See the section on Medical Clearance)

Patients with known allergies to late x , are currently or have in the past taken oral or IV Bisphosphonate medication, have active oral herptic lesions or any other disqualifying conditions listed in this booklet may NOT sit for the Clinical Examination. Candidates must place their initials, not their signature, at the bottom of the Medical History Form.

The Medical History and any physician’s statement will be reviewed by the Clinic Monitor on the clinic floor after patient submission and must accompany the patient at all times. If the patient sits for more than one candidate, a separate Medical History and Patient Consent, Disclosure and Release of Liability Forms must be completed for each examination.


Medical History and Consent, Disclosure and Release of Liability Forms: The Medical History and Consent, Disclosure and Release of Liability Forms must be completed and signed by the patient. Copies of each must be submitted for each patient treated.

Blood Pressure: The blood pressure must be taken and recorded on the Medical History Form on the day of the examination. If the patient is sitting for more than one examination in the same day, the blood pressure must be taken prior to each examination. (The blood pressure should be taken with the patient seated and arm extended and supported on the chair arm rest.)

o Patients with a blood pressure reading of 159 systolic or 94 diastolic and below may proceed without medical clearance.

o Patients with a blood pressure reading of or between 160 systolic or 95 diastolic and 179 systolic or 109 diastolic are accepted only with written clearance from the patient’s physician.

o Patients with a blood pressure reading equal to or greater than 180 systolic or 110 diastolic will not be accepted for this examination even if a consult from a physician authorizes treatment.

Pre-medication: A record must be kept for each patient who requires pre-medication prior to or during the course of the examination. For each patient treatment procedure, there is a place on the Progress Form to record the type(s) and dosage(s) of medication(s) administered. Candidates who are sharing a patient with a need for antibiotic prophylaxis must treat the patient the same clinical day. Treatment of the same patient on subsequent days will not be permitted.


INFECTION CONTROL PROCEDURES

The current infection control procedures recommended by the Centers for Disease Control and Prevention must be followed for the Patient Treatment part of the Clinical Examination. These procedures must begin with the initial setting up of the unit, continue throughout patient treatment and include final operatory cleanup. Failure to comply will result in the loss of points and any violation that could lead to direct patient harm will result in termination of the examination and loss of all points.

To the extent possible, dental professionals must prevent the spread of infectious diseases. Because many infectious patients are asymptomatic, all patients shall be treated as if they are, in fact, contagious. Use of barrier techniques, disposables whenever possible, and proper disinfection and sterilization are essential. The following infection control procedures shall be strictly adhered to:

Barrier protection

o Gloves must be worn when setting up or performing any intra-oral procedures and when cleaning up after any treatment. If rips or tears occur, new gloves must be donned. Gloves are not to be worn outside the operatory. Patients with known allergies to latex will NOT be allowed to participate for the examination

o Hands must be washed and dried between patients when visibly soiled or an alcohol based hand sanitizer may be used if hands are not visibly soiled whenever gloves are changed. No hand jewelry shall be worn that can tear or puncture gloves.

o Clean long sleeved uniforms, gowns, or laboratory coats are to be worn and must be changed if they become visibly soiled. Gowns or laboratory coats are to be removed before leaving the clinic area. Face masks and protective eyewear must be worn during all procedures in which splashing of any body fluids is likely to occur. Masks are to be discarded after each patient or sooner if the masks become damp or soiled.

o Footwear may not include sandals or open-toed shoes.

o Impervious-backed paper, aluminum foil or plastic wrap may be used to cover surfaces that may become contaminated. The coverings must be removed (while gloved), discarded, and replaced (after removing gloves) between patients.

o A clean patient napkin must be worn by the patient when he/she goes for evaluation.

o Candidates and patients must wear protective eyewear during all clinical procedures.

Sterilization and disinfections

INSTRUMENTS, GLOVES AND OTHER MATERIALS WHICH BECOME CONTAMINATED MUST BE PLACED IN APPROPRIATE RECEPTACLES.


Instruments. Any instrument that penetrates soft or hard tissue shall be disposed of or sterilized before and after each use. Instruments that do not penetrate hard or soft tissues, but do come in contact with oral tissues, shall be a single use disposable item and properly discarded or sterilized when appropriate.

NOTE: For sterilization and disinfection to be effective, all instruments must be pre-cleaned.

Surfaces and counter tops . If not barrier wrapped, surfaces and counter tops shall be pre-cleaned & disinfected with hospital level disinfectant that is tuberculocidal.

Handpieces, prophy angles, air/water syringes shall be sterilized before and after use or disposed of properly.

Used sharps are to be placed in a spill proof, puncture resistant container. Needles are to be recapped with a one-handed method or with special devices designed to prevent needle-stick injuries and disposed of properly.

All waste and disposable items shall be considered potentially infectious and shall be disposed of as is customary at the testing site in accordance with federal, state and local regulations.

Resuscitation equipment (sterilizable or disposable), pocket masks, resuscitation bags, or other ventilation devices will be provided by the administrators or school in strategic locations to minimize the need for emergency mouth-to-mouth resuscitation. Candidates should be familiar with their use.

Exposure to bloodborne pathogens. An exposure incident is defined as contact with blood or other potentially infectious materials (PIMS) through:

Needlestick, sharp or other percutaneous exposure, or Non-intact skin exposure such as an open cut, burn or abrasion, or Contact with a mucous membrane (e. g. inside nose, eye or mouth).

Since maximum benefit of therapy is most likely to occur with prompt treatment, the following policy has been established:

Immediately following the exposure incident, puncture wounds or other percutaneous exposures, skin exposures should be cleaned with soap and water. Mucous membrane exposed to blood or other PIMS should be extensively rinsed with water or sterile saline.

All percutaneous exposures and other exposures to blood and PIMS should be reported immediately to the Chief AES and the Examination Administrator so that appropriate measures can be initiated and the exposure incident documented

If possible, post-exposure prophylactic treatment should be initiated at the examination site if appropriate, as determined by the U.S. Dept. of Health and Human Services recommendations or appropriate referral made.

At the completion of all clinical examinations performed in operatories, it is the responsibility of candidates to thoroughly clean the operatory utilizing accepted infection control procedures.


GENERAL REQUIREMENTS

Patient Selection and Eligibility: For this Part of the Clinical Examination candidates must furnish their own patient. Patient selection and management is an important part of the examination and should be completed independently, without the help or assistance of faculty or colleagues. Candidates must carefully assess any physical or medical conditions which may be impacted by the examination process.

An individual who is physically or mentally disabled may, in most cases, be a patient in the examination. Candidates must contact the NERB a minimum of 60 days prior to the examination for authorization for patients with special requirements.

Consent, Disclosure and Release of Liability Forms: A Patient Consent, Disclosure and Release of Liability Form must be completed and signed by each patient prior to any treatment being rendered. Initially, only the candidate’s number should be recorded on the forms; the candidate’s name must be added after the examination is completed and before the candidate leaves the clinic after completing the entire Patient Treatment part of the Clinical Examination.

Anesthetic Record: Only topical anesthetics are permitted during the Clinical Examination. Prior to the start of the examination the candidate must complete the anesthetic record on the Progress Form whether or not the use of topical anesthetic is intended.

Radiographs: For the Patient Treatment part of the Clinical Examination a complete mouth radiographic series exposed within the previous three (3) years is required. In addition, four bitewing radiographs exposed within six months are required. These must be mounted separately from the complete mouth series unless the complete mouth radiographs have been taken within the previous six months; radiograph copies are acceptable.

If the current dentition is not represented on the above radiographs, they must be supplemented with current radiographs reflecting the change.

Panoramic and/or digital radiographs are NOT permitted for use in the Patient Treatment Clinical Examination.

The complete mouth series and bitewings must be properly mounted, according to ADA procedures (dimple up) with the exposure date, patient’s name, right and left sides indicated and candidate identification number noted. The diagnostically acceptable radiographs must demonstrate sufficient contrast to clearly display any pathoses. .

The radiographic films used in the examination will be collected at the end of the examination and become the property of the testing agency.


Treatment Selection: The candidate must select a primary quadrant of teeth for COMPLETE treatment to include removal of all supra and subgingival calculus as well as coronal plaque/stain.

The candidate must select twelve (12) surfaces of moderate subgingival calculus on at least six (6) and not more than eight (8) permanent teeth. A minimum of six (6) teeth must be in the primary quadrant with at least one (1) surface of calculus selected on each tooth. A majority of the surfaces of calculus selected must be in the primary quadrant.

Of the 12 surfaces:o Eight (8) surfaces must be on premolars and molars

Five (5) of the surfaces on premolars and molars must be inter-proximal surfaces in contact with an approximating tooth.

Three (3) of the interproximal surfaces must be on molars of which one (1) must be a multi-rooted molar in proximal contact with at least one (1) other tooth..

Four (4) remaining surfaces are at the choice of the candidate.

ALTERNATIVE SELECTION PROCESS: An alternate selection of up to two (2) contiguous molars in a quadrant, other than the primary quadrant, where the teeth are in contact with one another proximally may be utilized to meet the surface selection requirements in paragraph above if the required surfaces can not be met in the primary quadrant. The number of teeth upon which the subgingival calculus is selected may not exceed the maximum number of eight (8) teeth. Alternate teeth, if selected, must also be COMPLETELY treated (removal of supra and subgingival calculus as well as coronal plaque/stain).

Three pockets of 4 mm or greater in depth, each on a different tooth must be identified within the 6-8 teeth selected for treatment in the primary quadrant or alternative selection. The surfaces with the 4 mm or greater pockets so identified must have readily discernable calculus and must be within the twelve (12) surfaces selected for treatment.

The candidate must indicate the presence of moderate subgingival calculus on the Treatment Selection Worksheet by marking the appropriate letter for the surface in the box next to the number of the tooth selected for treatment. The first six (6) teeth in the primary quadrant will be listed in ascending order in the six boxes provided on the bottom of the scan sheet packet. On the day of the examination these selections will be entered on the Patient Treatment Evaluation Form. Each of the 6-8 selected teeth must have at least one surface of subgingival calculus charted.

The numbers of the selected teeth must be listed in ascending order. If subgingival calculus is on the line angles of the tooth, it must be marked on the interproximal surface, e.g. a deposit on the disto-facial line angle would be marked on the distal.

EXCLUSIONS : The following are strongly discouraged in the treatment selection of teeth:o Class III furcations or mobilityo Class IV periodontal pocketso Orthodontic brackets or bonded retainers o Implants included in the treatment selectiono Partially erupted 3rd molarso Retained deciduous teetho Gross carieso Faulty Restorationso Extensive full or partial veneers


o Multiple probing depths in excess of 6 mm

Calculus Detection: The presence of explorer-detectable moderate calculus on the twelve surfaces of the selected teeth must be accurately recorded. Only 12 surfaces of calculus must be recorded.

Pocket Depth Measurements: Pocket depths are accurately assessed and recorded on two (2) teeth assigned by a Clinic Monitor – one (1) posterior tooth and one (1) anterior tooth. Probing of the gingival sulcus and/or periodontal pockets must be accurate within 1 mm on all root surfaces of the two assigned teeth. Six measurements per tooth must be recorded.

Scaling: All subgingival surfaces of the teeth in the primary quadrant and any alternative teeth selected must be smooth, with no detectable deposits with an 11/12 ODU explorer. Air may be used to deflect the tissue to locate areas for tactile confirmation.

Polishing: All supragingival calculus, plaque and stain must be removed from the entire coronal surfaces of all teeth in the primary quadrant selected for treatment as well as any alternative teeth in another quadrant if selected so that the non-decalcified surfaces are visually clean when air-dried and tactilely smooth upon examination with an 11/12 explorer.


PATIENT CRITERIA:

Ambulatory with a medical history which permits dental treatment.

At least eighteen years of age and must be able to show proof of age.

A minimum of six natural teeth in the primary quadrant to be treated. Up to two contiguous molars in another quadrant may also be utilized if the teeth in the primary quadrant do not provide the necessary surfaces and locations of calculus required by the criteria. A maximum of eight (8) teeth may be used for the selection of the required twelve (12) surfaces of calculus.

Explorer-detectible, moderate calculus on each tooth in the primary quadrant and two contiguous molars in another quadrant if utilized. Each selected tooth must have at least one surface of calculus to be removed.

Three of the teeth must have a 4mm or greater pocket on the surface with calculus selected for calculus detection and removal.

A 4mm pocket is defined as when the gingiva completely covers the silver 4mm line on the required periodontal probe. Upon probing, ONLY black on the periodontal probe may be showing supragingivally.

At least one of the teeth selected for calculus detection and removal must be a multi-rooted molar in proximal contact with at least one other tooth.

None of the teeth selected may have a full crown restoration, be a primary tooth or an implant.

Patient Disqualification:

Patients who meet any of the following conditions are ineligible for this examination:

o HIV positive, have AIDS, or an ARC (Aids Related Condition).

o Hepatitis, infectious or serum (history or presently infected).

o Herpes with oral lesions present.

o Active venereal disease or Pregnancy.

o Tuberculosis.

o Dental professionals including, but not limited to: dentists, dental hygienists, dental assistants, licensed or unlicensed undergraduate dental or dental hygiene students.

o Require antibiotic pre-medication, unless accompanied by a letter from a licensed physician or dentist stating the antibiotic pre-medication has been administered, dispensed, or prescribed. There must also be a signed statement by the patient stating the medication has been taken.

o Considered "higher risk" by the American Heart Association (prosthetic heart valve) which would require IV or IM antibiotic coverage.

o Have been tranquilized or given anesthesia other than permitted by the examination guidelines.

o Currently taking or have in the past taken bisphosphonate medications either by IV or orally.

o Do NOT have generalized moderate calculus in the primary quadrant selected for treatment.

o Have an allergy to latex.


o Measured blood pressure reading that exceeds examination guidelines.


PATIENT TREATMENT PROCEDURES

The patient must be informed that this is an examination and additional treatment may be required to meet his/her oral health needs.

Only one patient may be presented for the Patient Treatment part of the Clinical Examination. Once a patient has been submitted to the Clinic Monitor with the Scan Sheet Packet and other required materials for assignment, an alternate patient may not be presented. If, before the patient is presented to the Clinic Monitor, the candidate finds the patient unacceptable for reasons they discern, an alternate patient may be used. The work-up of such patients is at the expense of the total time allowed for the Dental Hygiene examination process (4 hours).

A Treatment Selection Worksheet Form provided in the Application Packet may be completed prior to the day of the examination. Candidates are responsible for independently (without the help of faculty and/or colleagues) selecting and documenting teeth and surfaces for treatment that fulfill the published criteria. On the day of the examination the information on the Treatment Selection Worksheet must be accurately transferred to the Patient Treatment Evaluation Form. (Refer to the sample Dental Hygiene Treatment Selection Worksheet in the appendix for guidance.)

The Evaluation Forms (Scan Sheet Packet) for the Patient Treatment Clinical Examination and the Dental Hygiene Progress Form (see samples in this manual) are provided at the examination site. Place a barcode label, as indicated on all nine (9) pages of the Evaluation Forms and on the Progress Form. Enter the cubicle number on the Progress Form.

The procedures, instruments and materials used are the choice of the candidate, as long as these are currently accepted and taught by accredited dental hygiene programs and the candidate has been trained in their use. It is the responsibility of the candidate to provide the instruments used in this examination and listed in this Booklet unless such instruments are furnished by the school.

Candidates are to begin Patient Treatment in the designated clinic at either 7:30 A.M. or 1:00 P.M. as assigned by group.

On the day of and prior to the beginning of patient treatment, the patient shall be seated and the blood pressure taken, the records reviewed for accuracy and completeness. If the patient is sitting for more than one examination in the same day, the blood pressure must be taken prior to each examination.

The candidate must accurately transfer the information from the Treatment Selection Worksheet to the Dental Hygiene Patient Treatment Clinical Evaluation Form (Scan Sheet Packet) to include the three teeth and surfaces with 4 mm or deeper pockets, and the 6-8 teeth with twelve selected surfaces of moderate subgingival calculus detected and recorded by the candidate and the first six (6) teeth in the primary quadrant. The teeth should be listed in ascending order and the surface to be treated indicated in the smaller box to the right.

Candidates must complete the top portion of the Dental Hygiene Progress Form. The areas concerning anesthesia must be completed whether or not the use of a topical anesthetic is intended.


Candidates must do an intraoral and extraoral assessment of the patient prior to the examination and record any significant findings in the section labeled “Oral Assessment” on the Medical History Form.

During Patient Treatment, a Clinic Monitor is responsible for checking the candidate’s identification card and to observe the adherence to infection control protocols and proper patient management. If any problems arise during the examination the candidate should immediately notify a Clinic Monitor. The Clinic Monitor is also present to aid in any emergencies which may occur.

The Clinic Monitor will check and collect the patient’s:

Consent Form Disclosure Form Release of Liability Form

The Clinic Monitor will check:

Medical History Blood pressure Conformance of the tooth and surface selections recorded by the candidate with the

distribution criteria Approve or reject the anesthesia request Select one anterior and one posterior tooth within the primary quadrant and/or any

alternative selection for candidate probing purposes The assigned teeth must be probed by the candidate and all readings recorded

on the appropriate Scan Form PRIOR to submission of the patient to the Grading Clinic for Pre-Treatment Assessment

Proctors (Runners) will escort the patients and will carry the required forms to the Grading Clinic. The patients will carry their required instruments in an instrument cassette which has been sterilized in a sterilization pouch or wrap to the Grading Clinic. Only the patient may carry the tray with the cassette of instruments to the Grading Clinic. The following items must be presented on the instrument tray for Pre-Treatment evaluation.

Instruments (no scalers or curettes) in cassette:

Clear, new, un-tinted front surface, non-disposable mirror #11/12 ODU Hu-Friedy or American Eagle explorer (must be sharp) Metal periodontal probe Hu-Friedy CP UNC 12 SE

Air/water tip for the syringe Saliva injector

Note: The Progress Form, Evaluation Form, Medical History Form and radiographs must be carried by the Proctor. Do NOT turn in the Treatment Selection Worksheet.


The three examiners will independently evaluate:

Three teeth identified, each with a 4 mm or deeper pocket, must have a surface of calculus identified for removal.

6-8 teeth with, the 12 surfaces of subgingival calculus charted (including those in the first bullet immediately above) and evaluate the readings.

Pocket probing measurements by the candidate for the two teeth selected by the Clinic Monitor.

An AES will indicate a Start and Finish Time on the Dental Hygiene Progress Form. The total patient treatment time is 1 1/2 hours. However, all treatment must be completed by the end of the assigned examination time period.

When the patient returns to the candidate, treatment should begin. Treatment continues until it is completed or until the Finish Time, as noted on the Progress Form. If candidates finish the patient treatment before their assigned Finish Time, they may send the patient in for Post-Treatment evaluation. The candidate MUST scale all subgingival surfaces on all teeth in the primary quadrant and any alternative selection. Supragingival calculus, plaque and stain MUST be removed from all surfaces of teeth in the primary quadrant and any alternative selection.

By the stated Finish Time (or no later than 11:30 AM for the morning session or 5:00 PM for the afternoon session), each candidate should have completed subgingival calculus removal on all surfaces of teeth in the primary quadrant and alternative teeth if selected and removed all supragingival calculus, plaque and stain from those teeth. The patient must be signed-in for evaluation in the Grading Clinic by the recorded Finish Time. The use of disclosing solution is not permitted.

For the Post-Treatment evaluation, the candidate must send the following to the Grading Clinic on an instrument tray.

Instruments (no scalers or curettes) in cassette :o Clear, new, un-tinted front surface, non-disposable mirror o #11/12 ODU Hu-Friedy or American Eagle explorer (must be sharp)o Metal periodontal probe Hu-Friedy CP UNC 12 SE

Air/water tip for the syringe Saliva injector

Note: The Progress Form, Medical History Form and radiographs must be carried by the Proctor.

The patient, wearing a clean patient napkin, name tag, ID badge and safety glasses will be sent to the Grading Clinic.

The examiners will evaluate subgingival and supragingival calculus removal, stain and plaque

removal from all surfaces of all teeth in the primary quadrant and any alternate selection, recording their findings on the selected teeth and surfaces as well as tissue management.


If directed by the Examination Administrator or an AES a “Post-Operative Care Agreement”, available at the Proctor Desk, must be filled out stating that complete treatment was not provided during the examination process and that further arrangements need to be made to complete treatment. This form is to be signed by both the candidate and the patient.

When the patient returns from the Grading Clinic, the candidate must dismiss the patient, unless directed to do otherwise. The candidate must clean the clinic area following accepted infection control procedures.


FORMS

Evaluation and Progress Forms for each clinical examination will be provided to the candidate along with a supply of barcode identification labels.

Once the Examination begins, examination materials distributed by the testing agency may NOT be removed from the examining area

Forms may NOT be reviewed by unauthorized personnel

An example of each of these forms can be found in the Appendix of this booklet.

All forms must contain your candidate ID number and the examination identification number by affixing a barcode provided.

Each of these forms serves an important role in the examination process and is required unless otherwise stated.

Refer to the appendix of this booklet for an example of most forms.

o Dental Hygiene Treatment Selection Worksheet, which was mailed to each candidate and has an example in the appendix of this booklet, is used prior to the examination to select the required teeth and surfaces for treatment and pocket depth measurement. The information on this sheet is transferred to the Evaluation Form at the beginning of the examination and only the Evaluation Form is submitted.

o Evaluation Form is a multi-part scan form given to candidates at Orientation, it is used in scoring candidate performance. Place a barcode label within the bracketed area on each page of the form. Enter the selected teeth and surfaces with subgingival calculus to be removed, the numbers of the teeth with pockets of 4 mm or greater and subgingival calculus therein from within the teeth and surfaces selected for subgingival calculus removal, and the numbers of the first six teeth in ascending order in the primary quadrant selected for treatment. NO EXTRANEOUS MARKS are to be made on the Evaluation Form.

o Progress Form is utilized to record anesthetic, treatment provided, examiner signatures for all completed parts of the examination, and appropriate progress notes from the candidate to examiners during the course of treatment. Place a barcode label as indicated on the Progress Form, enter candidate cubicle number and patient’s name.

Note: Evaluation Form and Progress Form must be completed as directed and sent to the Grading Clinic at the time of Pre-Treatment evaluation. The Evaluation Form will remain in the Grading Clinic.

o Patient Consent, Disclosure and Release of Liability Forms as well as the Patient Medical History (with “Yes” answers circled in RED must be completed prior to entering the clinic. These forms are required for legal purposes and in case of emergency. The Consent, Disclosure and Release of Liability forms will remain with the Clinic Monitor and will not be seen by Examiners.


o Report of Equipment Failure – Used to document any university-owned equipment breakdowns. Additional time will be added to your total examination time to replace any lost time due to university-owned equipment. FAILURE OF YOUR OWN EQUIPMENT IS YOUR RESPONSIBILITY, AND YOU WILL NOT BE GIVEN ADDITIONAL EXAMINATION TIME.

o Clinic Attendance Form and Check-Out Sheet – Used to document your presence in the clinics. Any time you enter or leave the clinic, it must be documented.

o Instruction to Candidate Form: Candidates may receive written instructions on an “Instruction to Candidate” Form from the Clinic Monitors in the Candidate Clinic to modify their record documentation or treatment. If an Instruction to Candidate Form is received from the Grading Clinic, the candidate must immediately summon a CM or AES prior to carrying out any of the instructions and summon the same CM or AES for a completion check. The candidate must initial on the Instruction to Candidate Form that the instructions are understood.

o Follow-Up Form is utilized whenever the treatment provided results in a serious clinical problem. This form identifies the problem and establishes responsibility for further treatment. The patient is informed that follow up is necessary, financial responsibility is clarified and the candidate and AES must sign the form.


EXAMINATION SCORING

Candidates will receive separate score reports of each of the two parts of the Clinical Examination. If all of the Patient Treatment part of the Clinical Examination is not taken, a score of “0” will be recorded for that part.

Computer Simulated Part of the Clinical Examination (CSE-FL) - 100 Points

The Computer Simulated Clinical Examination consists of 100 graded questions and the score for this examination is based on the percent of questions answered correctly. A final score of 75% or higher is passing. There may be additional questions included on the CSE-FL examination that are being evaluated for future use. These additional questions will not be counted or considered in the grading of your examination.

Patient Treatment Part of the Clinical Examination - 100 Points

The Patient Treatment part of the Clinical Examination consist of Case Acceptance and Treatment Evaluation.

During Case Acceptance candidate performance is evaluated according to four defined competency levels. Candidates are evaluated on whether or not their submitted patient meets the published examination requirements.

Candidate submission of exactly 12 surfaces of explorer-detectable subgingival calculus on at least six teeth in a primary quadrant and/or not more than two contiguous molars in another quadrant, not to exceed eight (8) teeth on which the 12 surfaces of subgingival calculus are identified by the candidate;

The two (2) contiguous molars in another quadrant may be used if necessary to meet the criteria.

The primary quadrant is the quadrant with the majority of teeth and subgingival calculus surfaces selected.

At least three of the selected teeth must have a periodontal pocket of 4mm or greater in depth on the surface with identifiable calculus.

Accurate pocket depth measurements on two teeth (one anterior and one posterior) in the primary quadrant selected by the Clinic Monitor; six measurements per tooth.

During Pre-Treatment Evaluation the examiners in the Grading Clinic independently determine: Whether each of the three teeth identified with pockets of 4 mm or greater meet that criteria. Whether or not subgingival calculus is present as identified by the candidate on the 12selected.

tooth surfaces including those on which the three pocket depths of the 4 mm or greater identified above; and

Whether each of the 12 pocket depth measurements by the candidate on the two teeth selected by the Clinic Monitor is accurate.

During Post-Treatment Evaluation the Examiners independently determine;Florida CIB Dental Hygiene 06_2010

36

Whether the existing subgingival calculus is removed and appropriate root planning (biofilm removal) is performed.

Whether or not supragingival calculus/plaque/stain has been removed. Whether patient comfort, damage to adjacent soft and hard tissue expectations were adhered to. Whether the overall treatment of the primary quadrant and any alternative tooth/teeth in another

quadrant selected was performed appropriately.

The examination Scoring System primarily uses an additive approach for procedures performed. Additionally, there are penalty points that may be deducted from the total additive score.

Three Examiners will independently evaluate all treatment criteria for the examination and the median competency level in each category is translated into a numerical score.

Grading Competency Levels

There are four competency levels used by Examiners to rate clinical skills. The following are explanations of the competency levels as they apply to the Patient Treatment part of the Clinical Examination.

Satisfactory (SAT)The treatment is of good to excellent quality, demonstrating competence in clinical judgment, knowledge and skill. The treatment adheres to accepted mechanical and physiological principles.

Minimally Acceptable (ACC)The treatment is of acceptable quality, demonstrating competence in clinical judgment, knowledge and skill to be acceptable; however, slight deviations from the mechanical and physiological principles of the satisfactory level exist which do not damage the patient.

Marginally Substandard (SUB)The treatment is of poor quality, demonstrating a significant degree of incompetence in clinical judgment, knowledge or skill of the mechanical and physiological principles.

Critically Deficient (DEF)The treatment is of unacceptable quality, demonstrating critical areas of incompetence in clinical judgment, knowledge or skill of the mechanical and physiological principles of dental hygiene.

Points or Penalties are assigned as follows:

Case Acceptance: Penalties are assessed for those areas that do not meet the described criteria for case acceptance.

Calculus Detection and Removal: 78 Points total – 6.5 points are awarded for each of the twelve surfaces of subgingival calculus identified by the candidate that are correctly detected and removed . A minimum of Nine (9) surfaces of calculus must be correctly identify and removed in order to pass the examination.

o In the event that two or three of the Examiners cannot independently confirm the presence of subgingival calculus on a surface identified by the candidate as having calculus present, the


candidate will not be awarded any of the 6.5 points allocated for calculus detection and removal for that surface.

o If subgingival calculus, as determined by two or three Examiners independently, remains on a surface that was selected for treatment by the candidate, the 6.5 points allocated for that surface are not awarded.

Periodontal Measurement: 12 Points – one point is awarded for each of six measurements on the two assigned teeth that two or three of the Examiners agree independently is accurate.

Plaque/Stain/Supragingival Calculus Removal: 6 Points – one point is awarded for each of the first six teeth selected in ascending order by the candidate that two or three Examiners agree meets the Post-Treatment criteria.

Treatment Management: Up to 4 Points may be awarded for patient and tissue management that meets the described criteria. Penalties assessed by Clinic Monitors (CM) for such categories as patient management and infection control will be computed and deducted from the final score. Critical errors are given special consideration. Critical errors are circumstances or conditions that could lead to patient injury or may jeopardize overall treatment of the patient. A critical error, such as a laceration of the soft tissue that requires suturing will result in failure of the Patient Treatment part of the Clinical Examination even though other rated treatment criteria are acceptably completed.

Penalty Deductions

The scores for the Patient Treatment part of the Clinical Examination may also be affected by certain conduct or errors on the part of a candidate that warrant a penalty deduction from the examination score. Throughout the Clinical Examination the conduct and clinical performance of the candidate will be observed and evaluated. Penalties may be assessed for violation of the Clinical Examination standards or for certain procedural errors as described below.

The following penalties shall be applied to the overall score:

o ACC, SUB, DEF (5, 15, 30 point deductions, respectively, in Case Acceptance and are not cumulative within the Case Acceptance category);

o One pocket depth of 4 mm or greater not present (15 point deduction);o Two or three pocket depths of 4 mm or greater not present (30 point deduction); o Violation of universal precautions (1 point deduction); o Gross infection control violation (10 point deduction); o Disregard for patient comfort (10 point deduction);o Unprofessional demeanor: unkempt, unclean, or unprofessional appearance; inconsiderate or

uncooperative behavior with other candidates, examiners or testing site personnel (1 point deduction);

o Improper management of significant history or pathosis (10 point deduction);o Improper operator/patient position (1 point deduction);o Improper or incomplete record keeping (1 point deduction);o Nondiagnostic radiographs,(100 point deduction);


o Treatment of teeth other than those in the primary quadrant and/or alternative selections (10 point deduction);

o Violation of examination standards, rules or guidelines (100 point deduction);o Failure to complete treatment within the stated time guidelines (100 point deduction);o Critical lack of diagnostic/clinical judgment skills (100 point deduction).

This penalty would be applied when the candidate’s lack of clinical judgment or clinical skills seriously jeopardizes the prognosis of the treatment and/or the patient’s well-being.

The serial listing of penalties or deficiencies does not imply limitations, since some procedures will be classified as unsatisfactory for other reasons, or for a combination of several deficiencies.

Any of the following will result in failure of the entire examination:

o Falsification or intentional misrepresentation of application requirementso Cheating (Candidate will be dismissed immediately)o Any candidate demonstrating complete disregard for the oral structures, welfare of the patient

and/or complete lack of skill and dexterity to perform the required clinical procedures. o Misappropriation of equipment (theft)o Receiving unwarranted assistanceo Alteration of examination records and/or radiographs


Scoring Information And Grade Notification

Scoring Procedures

Please refer to 64B5-2.0135 "Dental Hygiene Examination" for comprehensive grading criteria information

The Clinical Examination score is based on a system of independent corroboration of point awards and penalties for identified errors. Three Examiners independently grade each procedure and mark compliance and/or identified errors on a computer scan sheet.

If two or more Examiners have identified compliance or an error, their markings are compared by the computerized scoring system and point awards and/or penalties are considered for scoring.

Your score will be based on the number of agreements or corroborated errors detected by each Examiner (grading independently).

The Examiners will not see any candidates during the Clinical Examination. Examiners will grade independently and you will be known to the Examiners only by your candidate number.

Notification Of Results

Preliminary scores will be available at the examination site the day after completion of the Patient Treatment part of the Clinical Examination at a time announced at the Candidate Orientation.

Your Official Score will be available approximately 10 business days following your clinical examination on the Testing Services website at: http://ww2.doh.state.fl.us/ONLINETESTNET/default.aspx

o You will need your social security number and date of birth to access your grade results.

o Grade results CANNOT be given out over the telephone.

o Grade results CANNOT be picked up in person.

o Grade results WILL NOT be sent by mail.

Please do NOT call the Board Office or Testing Services for this information


EXAMINATION CRITERIA

DENTAL HYGIENE PATIENT TREATMENT EXAMINATION

PATIENT SELECTION

SATISFACTORY

1. The Medical History, Progress Form and Evaluation Form are complete, accurate and current.2. The systolic and/or diastolic blood pressure are equal to or less than 159/94 or the systolic and/or

diastolic blood pressure are equal to or between 160/95 and 179/109 WITH a written consult from a physician authorizing treatment during the examination.

3. Radiographs are of diagnostic quality, reflect the current clinical condition of the mouth, the periapicals exposed within 3 years and four bitewings within 6 months and are properly mounted with the Candidate ID #, properly labeled R and L, exposure date and patient’s name.

4. The Calculus Detection portion of the Evaluation Form is properly completed, indicating: - 6-8 teeth selected, each with at least one surface of subgingival calculus charted.

- A minimum of 6 teeth in the primary quadrant selected. - Exactly 12 surfaces of subgingival calculus charted.

- 8 of the 12 surfaces are on premolars and/or molars (posterior teeth). - 5 of the selected surfaces must be on posterior interproximal surfaces in contact with an

approximating tooth and 3 of these must be on molars, one of which is a multi-rooted molar. - All posterior teeth on which a surface of subgingival calculus is identified for removal must be in contact with a contiguous tooth.

- Three pockets 4 mm or greater in depth, each on a different tooth within the 6-8 teeth selected and including a surface of calculus identified for removal.

MINIMALLY ACCEPTABLE

1. The Medical History is incomplete*, missing patient signature*, or has slight inaccuracies which do not affect the patient or proposed treatment.

2. The Progress Form and/or Evaluation Form has inaccuracies or is incomplete or missing.*3. Blood pressure has not been taken or is not recorded* but upon correction meets criteria listed under

Satisfactory. 4. Radiographs are available but not submitted with the patient for initial evaluation*** 5. The Calculus Detection portion of the Evaluation Form has not been filled out or on the first submission

is filled out incorrectly demonstrating:- Fewer than 6 or more than 8 teeth are selected with subgingival calculus identified**, and/or- More or less than12 surfaces of subgingival calculus charted** and/or - Fewer than 8 surfaces of subgingival calculus charted on premolars and/or molars** and/or no approximating tooth is in contact with the tooth on which a surface of calculus is selected by the candidate for detection and removal** and/or- One or more selected teeth without any surfaces of calculus charted** and/or- Fewer than 5 selected surfaces on posterior interproximal surfaces** and/or fewer than 3 of these on molars, one being a multi-rooted molar** and/or- Fewer than 3 separate teeth with pockets of 4 mm or greater indicated for Pocket Depth Qualification and/or one or more teeth are outside the treatment selection.** and/or


- One or more of the 3 separate teeth with pockets of 4 mm or greater with a surface of calculus identified and selected for removal are not included in the 6-8 teeth and 12 surfaces with subgingival calculus identified and selected for removal.**

* The Clinic Monitor will provide the candidate with an Instruction to Candidate requesting correction. ** The Clinic Monitor will provide the candidate with an Instruction to Candidate requesting correction and a second Evaluation Form. The Evaluation Form with errors will be retained by the AES and placed in the Candidate File. *** Instruction to Candidate is sent requesting radiographs.

MARGINALLY SUBSTANDARD

1. Medical History has inaccuracies which do not affect treatment but demand immediate attention*. Medical Clearance is not present on submission for assignment but available on request.

2. Radiographs are of poor diagnostic quality and/or do not meet all of the criteria under Satisfactory. 3. Of the three separate teeth indicated with pocket measurements of 4 mm or greater in depth, less than

three of the separate teeth are included in the selection and/or one or more of these teeth are outside the treatment selection on the second submission.*

4. Second submission of incomplete and/or incorrect Pre-treatment Evaluation Form or Progress Form.*

* The Clinic Monitor will provide the candidate with an Instruction to Candidate for correction.

CRITICAL DEFICIENCY

1. Medical History has significant findings contraindicating treatment e.g. latex allergy, taking non-approved bisphosphonates, active herpes infection, patient is pregnant. (Patient Treatment Examination is stopped).

2. The Systolic and/or diastolic blood pressure is equal to or between 160/95 and 179/109 WITHOUT a written consult from a physician authorizing treatment OR the systolic and/or diastolic blood pressure is equal to or greater than180/110 even with a written consult from a physician authorizing treatment. (Patient Treatment Examination is stopped).

3. Radiographs (full mouth series and bitewings) are of unacceptable diagnostic quality and/or are missing and not available on request. (Patient Treatment Examination is stopped).


DENTAL HYGIENE PATIENT TREATMENT EXAMINATION

TISSUE AND TREATMENT MANAGEMENT

SATISFACTORY

1. Instruments, polishing cups or brushes and dental floss are effectively utilized so that no unwarranted soft or hard tissue trauma occurs as a result of the scaling and polishing procedures.

MINIMALLY ACCEPTABLE

1. There is slight soft tissue trauma that is consistent with the procedure.

MARGINALLY SUBSTANDARD

1. There is soft tissue trauma that is inconsistent with the procedure. Soft tissue trauma may include, but not be limited to, abrasions, lacerations or ultrasonic burns.

2. There is hard tissue trauma that is inconsistent with the procedure. Hard tissue trauma may include root surface abrasions that do not require additional definitive treatment.

3. There is a lack of complete debridement (removal of supra and/or subgingival calculus, plaque and stain) of the teeth in the primary quadrant and/or the alternative teeth selected that were not included in the detection or removal selection of the 6-8 teeth, 12 surfaces.

4. One amputated papillae (facially and lingually).

CRITICAL DEFICIENCY

1. There is major damage to the soft and/or hard tissue that is inconsistent with the procedure and pre-existing condition. This damage may include, but not be limited to, such trauma as:

- Amputated papillae (2 or more facially and lingually).- Exposure of the alveolar process.- A laceration or damage that requires suturing and/or periodontal packing.- A broken instrument tip is evident in the sulcus or soft tissue.- Root surface abrasions that require additional definitive treatment.- One or more ultrasonic burns that require follow up treatment.


Post-Examination Procedures

Passing Candidates

Candidates who pass the examination will receive additional licensure information from the Board Office. Your license will be for the biennial period ending February 28, 2012.

Failing Candidates

Any candidate who fails to pass the examination will be required to retake the examination in order to become licensed in the State of Florida.

Reexamination Information

Please contact the Board Office for specific information regarding re-examination:

o Re-examination fees and/or application

o Application deadline

Please see the Testing Services website for future examinations dates.

Requirements:

o Any candidate, who passes one Portion (e.g. Laws and Rules or Clinical) of the examination, needs to retake only the Portion that was failed.

o Any candidate who passes only one Part (e.g. CSE-FL or Patient based) of the clinical examination, needs to retake only the Part that was failed.

o Any candidate who fails ONLY the Laws & Rules Examination may retake that examination as soon as their application has been approved by the Board Office.

o A candidate must successfully complete both portions of the examination (Laws & Rules and Clinical) within a 13 period in order to qualify for licensure. If the candidate fails to successfully complete both portions within that time period, then the candidate must retake the entire examination.

o Any candidate who fails to pass the clinical portion of the examination in three attempts shall not be eligible for re-examination until he/she successfully completes one academic semester of clinical course work at the senior clinical practice level at a dental hygiene school approved by the American Dental Association Commission on Accreditation. The candidate must furnish proof from the accredited dental hygiene school of his/her successful completion of the course work.


Post- examination Review Process

Each candidate who takes and fails the examination is provided the opportunity to review the examination questions, answers, grades, papers, and grading keys which they answered incorrectly. A post-examination review is NOT required and will NOT alter a failing grade in any way. See Rule 64B-1.013, Florida Administrative Code, for rules regarding post-examination reviews.

ALL REQUESTS FOR A REVIEW MUST BE POSTMARKED WITHIN 21 DAYS FROM THE DATE OFFICAL SCORES ARE RELEASED ON THE TESTING SERVICES WEBSITE. Reviews are completed within 60 days after the date on the grade notification. Generally, candidates are granted 45 minutes for a post-examination review of the Clinical examination. Only the candidate and the appropriate DOH representatives will be allowed in the Review Room. The same security requirements observed at the examination will be followed during the review process. If a candidate arrives late for a post-examination review appointment, they will not receive extra review time. Candidates may NOT bring anything into the post-examination review session. No talking between candidates is allowed during the post-examination review. No examination materials may be removed from the review site. Any observance or evidence of a candidate attempting to copy or remove test items, questions, booklets, or other examination materials will be fully documented in writing. The written report will be referred to the Board Office and Department of Health Investigative Services for actions deemed appropriate.

If you wish to review your examination, please fill out a “Post-examination Review Request Form” (located in the Appendix of this booklet) and mail it, with your check or money order, to Testing Services, DOH, at the contact information on the last page of this booklet.

Election of Hearing Rights

Under Florida law, if you failed your licensure examination by less than 10 percent of the grade required for passing, you can contest the examination. To do this, you must request a hearing by choosing one of the options set forth below and filing your petition with the Agency Clerk. The petition must be post-marked within 21 days from the date the Department has posted Official examination grades, or if you plan to review, or have reviewed your examination, within 21 days of the date of your review of the examination.

Your petition must be received by the Agency Clerk post-marked within the above-stated 21 day period at the following address:

AGENCY CLERKFlorida Department of HealthOffice of the General Counsel4052 Bald Cypress Way, BIN A02Tallahassee, Florida 32399-1703

Administrative Hearing Option Ao If you are not disputing the examination’s grading, scoring, validity as a testing tool, or

methodology, you may request a Hearing Not Involving Disputed Issues of Material Fact. This hearing will be by the professional Board that regulates your specific profession or the Department of Health if there is no Board for that profession. Although the Board’s greatest authority is limited to ordering a free re-take of the examination, or a section of the examination, you will be given an opportunity to appear at a scheduled Board hearing and present your case to the Board. Your petition must be in substantial compliance with Rule 28-106.301, Florida Administrative Code. If you elect this option, you will not be able to dispute anything relating to


the examination itself, and the Department will not re-grade your examination. You will only be allowed to explain how mitigating factors such as external conditions, loud noises, or temperature affected your ability to take the examination.

OR

Administrative Hearing Option Bo If you dispute anything related to the examination’s grading, scoring, validity as a testing tool, or

methodology, you may request a Hearing Involving Disputed Issues of Material Fact. This hearing will be before an Administrative Law Judge. Your petition will be forwarded to the Division of Administrative Hearings and your petition must state all disputed facts pertaining to the exam questions and/or procedures, and be in substantial compliance with Rule 28-106.201, Florida Administrative Code.

Please be advised that the administrative hearing process is lengthy and it may take 6 to 12 months, or longer, before a final decision is made. The Department will be represented by an attorney and may offer the testimony of one or more expert witnesses. You are hereby notified, pursuant to Section 120.573, Florida Statutes, that mediation is not available to resolve these issues.


EVALUATION – GENERAL RULES

All necessary materials and instruments for the Patient Treatment Clinical Examination, other than the operatory chair, light and dental unit, must be provided by the candidate.

o Ultrasonic units for candidate use are NOT available at all sites.o Ultrasonic units are provided at the University of Florida and Miami Dade College sites

and require a 30K tip. Candidates may NOT use personal ultrasonic units at these sites.o Ultrasonic units are NOT available at the Palm Beach State College site and candidates

will need to provide their own ultrasonic unit. The attachment indicated in the appendix is necessary and must be provided by the candidate.

Candidates must wear operating attire consistent with CDC regulations. No personal identification of the candidate may appear on candidate clinical attire. Photo Identification Cards, supplied by the NERB, must be worn at all times during the clinical examinations by the candidates, the patients, and any registered interpreter.

Only authorized personnel will be allowed in the clinical areas.

Performance of the candidate will be evaluated according to the published criteria and the standards.

Evaluation of clinical performance is conducted in an anonymous manner. Evaluating examiners are unaware of the identity of the candidate whose performance is being evaluated.

Any candidate demonstrating disregard for the oral structures, aseptic techniques, welfare of the patient and/or lack of skill and dexterity to perform the assigned clinical procedures may be immediately dismissed from the examination upon agreement of two examiners. The Chief AES and Examination Administrator will be notified immediately.

In the event that any serious clinical problems occur as a result of the treatment provided during the examination, arrangements must be made for the patient to receive follow-up care. A Follow Up Form will be provided as a record of the patient’s needs. The candidate should give prior consideration to what arrangements might need to be made for patients to receive follow-up care.

An appropriately sized Instrument Cassette and tray must be provided by the candidate for the patient to transport instruments and materials to and from the Grading Clinic.

Check-out Procedure following the completion of the Patient Treatment Examination.

Upon completion of the examination and when ready to check out, all white envelopes in which examination materials were received must be personally submitted at the desk. The following items must be enclosed in the white envelope and accounted for prior to dismissal from the examination site:


Photo Identification card for candidate and White Admission Slip if not staying to receive grades the following day.

Unused Evaluation Forms.


EXAMINATION EQUIPMENT, PROCEUDRES AND PROCESSES :

REQUIRED: YOU MUST BRING THE REQUIRED INSTRUMENTS FOR USE BY THE EXAMINERS DURING CASE ACCEPTANCE AS WELL AS PRE-TREATMENT AND POST-TREATMENT EVALUATION.

For each examination phase, Case Acceptance, Pre-Treatment, and Post-Treatment Evaluation you will need at least one (1) set of instruments that are in sterilized cassettes and sealed in sterilization packages.

o Write either “Acceptance” or “Grading” and your Candidate ID number on the respective set of instruments.

o Each set of instruments must contain:

Explorer – Double-ended #11/12 ODU (Hu-Friedy or American Eagle brand)

Periodontal Probe – Hu-Friedy CP UNC 12 SE

Mouth Mirror – Clear, un-tinted front-surface, NON-DISPOSIBLE

Several gauze sponges

Several cotton rolls

Saliva injectors

Air/Water Tips: Requirements may be unique to each examination site; Tips should be in a separate package.

o Gainesville Site - Pinnacle SealTight air/water syringe tips

o Miami-Dade Site - Dentsply Sani-tip air/water syringe tips

o Palm Beach Site - Safe-Tips EZ deposable tips Kerr (formally Pinnacle)

WARNING: You will not be given any additional time for delays that may result from the presentation of incorrect or improperly packaged instruments.

NOTE: You must bring separate instruments for your own use.

Presenting Your Patient for CASE ACCEPTANCE:

When you have verified form completion and are satisfied that your patient qualifies for the examination, you will summon the Clinic Monitor to submit your patient.

Your patient and paperwork will be reviewed to determine whether they meet all of the Case Acceptance requirements by a Clinic Monitor who will then assign one anterior and one posterior tooth for probing.

You must measure the sulcus depths on the one anterior and one posterior tooth assigned by the Clinic Monitor and record your findings in the boxes provided on the Progress Form. THIS MUST BE DONE PRIOR TO SENDING YOUR PATIENT FOR PRE-TREATMENT EVALUATION.

Your must submit your patient with an instrument cassette, protective eyewear, wearing a clean napkin, and their patient badge, which must be clearly visible:

o Medical History Form


NOTE: If your patient checked "yes" for one of the items under the section titled, "Do you have a history of the following?" your patient MAY still be accepted.

o Progress Form

o Evaluation Form

o Radiographs

o For Case Acceptance, you will need at least one (1) set of instruments that are in sterilized cassettes and sealed in sterilization packages.

o Write “Acceptance” and your Candidate ID number on each package of instruments.

NOTE: THE PATIENT MUST BRUSH THEIR TEETH BEFORE LEAVING CASE ACCEPTANCE FOR PRE-TREATMENT EVALUATION.

WARNING: The omission of information or the reporting of incorrect information on ANY form may be considered fraudulent or deceitful and may result in denial of licensure.

As a rule, CLINIC MONITORS AND EXAMINERS WILL REJECT PATIENTS WHO CANNOT EASILY BE ACCOMMODATED IN A TYPICAL DENTAL OFFICE.

After Case Acceptance a proctor will escort your patient, along with their forms and instruments to the Grading Clinic for Pre-Treatment Evaluation.

NO ADDITIONAL NOTES MAY BE USED FOR THE EXAMINATION OTHER THAN THOSE HAND-WRITTEN BY THE CANDIDATE IN THE CANDIDATE INFORMATION BOOKLET.

NOTE: Periodontal charts are allowed for your own use. They are not required and will not be given to the Examiners. These charts will NOT be part of the official examination file.

Presenting Your Patient for PRE-TREATMENT and POST-TREATMENT GRADING :

REQUIRED: YOU MUST BRING THE REQUIRED INSTRUMENTS FOR USE BY THE EXAMINERS DURING PRE-TREATMENT and POST-TREATMENT EVALUATIONS

You are required to perform a partial prophylaxis.

o ALL PLAQUE, STAIN, SUPRAGINGIVAL AND SUBGINGIVAL FOREIGN DEPOSITS MUST BE REMOVED FROM ALL SELECTED TEETH.

When you have completed probing the one anterior and one posterior tooth assigned by the Clinic Monitor at Case Acceptance and recorded the measurements in the area provided on the Progress Form, and you wish to present your patient for Pre-Treatment evaluation, ---as well as when you are finished working on your patient after Pre-Treatment evaluation is completed and wish to present your patient for Post-Treatment evaluation, or when time is called, you will present to the Clinic Monitor:

o Your patient with instrument cassette, protective eyewear, wearing a clean napkin, and his/her patient badge, which must be clearly visible.

o Medical History Form

o Progress Form

o Radiographs


o For each, Pre-Treatment and Post-Treatment, you will need at least one (1) set of instruments that are in sterilized cassettes and sealed in sterilization packages.

Write “Grading” and your Candidate ID number on each package of instruments.

A proctor will escort your patient with grading instruments between the Candidate and Grading Clinics for both Pre-Treatment AND Post-Treatment evaluation.

Upon completion of the Pre-Treatment evaluation, the AES in the Grading Clinic will assign a Post-Treatment STARTING and FINISHING time defining the 1 ½ hours (90 minutes) allocated for your treatment of the patient.

o When your patient returns from Pre-Treatment to the Candidate Clinic you MUST wait for the Clinic Monitor notification to begin the treatment phase of the examination.

When you have completed the treatment phase on your patient summon the Clinic Monitor and present for Post-Treatment evaluation.

If you have not already presented your patient for Post-Treatment evaluation you MUST immediately put down your instruments and stop working when the Clinic Monitor announces that the examination has concluded.

Both hand and ultrasonic instruments are permitted for this procedure. Slow speed rotary instruments may be used to polish the teeth surfaces.

YOU MUST REMAIN QUIET IN YOUR OPERATORY DURING BOTH OF THOSE GRADING PERIODS.

NOTE: EXAMINATION TREATMENT TIME WILL END 1½ HOURS (90 minutes) from the START time assigned at Pre-Treatment evaluation by the AES or at the end of the examination period.

Examiner Grading and Operatory Clean-Up:

Your patient will be independently graded by three Examiners for Pre-Treatment evaluation and Post-Treatment evaluation.

During the time your patient is in the Grading Clinic for Post-Treatment evaluation, you should take time to clean your operatory using sterile techniques.

Once your patient has returned from Post-Treatment evaluation, and your operatory is clean, you may check out with the Clinic Monitor and proctor desk and leave the clinic.


Equipment And Supplies

ALL NECESSARY MATERIALS AND INSTRUMENTS FOR THE PATIENT TREATMENT CLINICAL EXAMINATION, OTHER THAN THE OPERATORY CHAIR, LIGHT AND DENTAL UNIT, MUST BE PROVIDED BY THE CANDIDATE.

The Examination Administrators will supply only the equipment that is at the examination site.

You must have everything needed at the scheduled starting time of your examination session.

The Board of Dentistry, the North East Region Board of Dental Examiners, Inc, or the Department of Health are not responsible for your personal/rented equipment and supplies.

WARNING: It is your responsibility to bring only approved items to the examination. All candidates’ tackle boxes, as well as any other equipment or supplies, are subject to random search by Clinic Monitors or Department personnel. If an item that is not authorized is found, the incident will be fully documented and reported to the Board of Dentistry. The minimum sanction for possession of unauthorized materials is to declare the candidate’s examination scores invalid.

Required Materials:

You are responsible for presenting the correct instruments. If packages of instruments are purchased, it is your responsibility to ensure the instruments are correct.

WARNING: Occasionally, probes with manufacturing defects have been obtained by candidates. Please inspect all probes to be sure they are correct in length and markings.

REQUIRED: You MUST submit sealed, sterilized sets of instruments in cassettes for examiner use during Case Acceptance, Pre-Treatment, and Post-Treatment Grading.

Total materials needed:

For Case Acceptance, Pre-Treatment and Post-Treatment you will need a total of at least three (3) separate sets of instruments that are in sterilized cassettes and sealed in sterilization packages.

o It is recommended that AT LEAST one back-up set of instruments (a 4th set) be available for mishaps such as dropping instruments on the floor, prior contamination, etc.

o Sterilization facilities will not be available to candidates at the examination site.

Gauze sponges – Several - 2 inch by 2 inch

Cotton rolls – Several

Disposable saliva ejectors – Several

Gloves – Several

Masks – Several

Paper towels – Several

Garbage bags

Antibacterial soap

Tray - for carrying instruments between clinics


Clip Board for use during Form completion

Air/Water Syringe Tips

o Gainesville Site – Sufficient, Pinnacle SealTight air/water syringe tips.

o Miami-Dade Site – Sufficient, Dentsply Sani-tip air/water syringe tips

o Palm Beach Site – Sufficient, Safe-Tips EZ deposable tips Kerr (formally Pinnacle)

Toothbrushes – Two - new toothbrushes in original packages.

Patient Napkins – Several - a fresh napkin must be placed on your patient before sending to the Case Acceptance and Grading areas. In addition, you must remove the patient’s napkin anytime they leave the clinic for any reason other than going to the Grading Clinic (e.g. to go to the restroom).

Patient Eye Protection – Glasses for eye protection must be worn by your patient.

Candidate Eye Protection – The use of eye protection devices is REQUIRED. Visor-type shields are acceptable as eye-wear, but NOT as a replacement for the required mask.

ODU Explorer – Three - double-ended #11/12 ODU (Hu-Friedy or American Eagle brand) An explorer will be REJECTED if it is not a fine and sharp instrument. This requirement has been made in order to aid Examiners in consistent evaluations.

Periodontal Probe – Three Hu-Friedy CP UNC 12 SE. May be color coded.

Mouth Mirror – Three - NEW un-tinted front-surface, NON-DISPOSIBLE (Mouth mirrors that are clouded, tinted, or unclear will be rejected.)


Instruments for Candidate Use During Treatment:

Handpieces

o GAINESVILLE SITE – Slow-speed handpieces must be a Midwest or Midwest-like 4-hole back-end; other types may not work.

o Miami-Dade Site: two hole slow speed handpiece connecter; refer to appendix for diagram

o Palm Beach Site: two hole slow speed handpiece connecter; refer to appendix for diagram

Omron Automatic Blood Pressure Monitor with memory capacity

o NOTE: Due to their memory capability these monitors are not to be shared between candidates/patients.

Prophylaxis angle to adapt to the required handpiece.

Supplies customarily used in an oral prophylaxis, including saliva ejectors.

Hand instruments scalers and polishing instruments used for an oral prophylaxis.

NOTE: Candidates will NOT be given any additional time for personal equipment failures or problems.

NOTE: You are responsible for the working condition of all handpieces and personal equipment. If you are renting or borrowing such equipment, you must take your own time to become familiar with the proper use of the equipment.

Optional Materials:

Ultrasonic instruments – You are allowed to use the PROVIDED ultrasonic instruments if you desire. Please refer to the hook-up available at each site (located in the Appendix of this booklet).

o The University of Florida provides Cavitron SPS ultrasonic scalers. Candidates are required to provide their own Steri-Mate handpiece and 30K inserts.

o Miami-Dade College provides Dentsply Ultrasonic Model 3000. Candidates are required to provide their own handpiece and 30K inserts.

o Palm Beach State College DOES NOT provide ultrasonic scalers for candidate use. Candidates must provide their own with the appropriate college.

Topical anesthetic gel – You will be allowed to use topical anesthetic gel if you desire. ONLY commercially available topical gel, which is clearly intended for use on humans, and is in its original container, may be used. In addition, Oraqix in its original container may be used.


Prohibited:

NOTE: NEITHER CANDIDATES NOR PATIENTS MAY HAVE THESE MATERIALS IN THE EXAMINATION CLINICS.

o study and/or reference materials; with the exception of this Candidate Information Booklet

o purses, briefcases, portfolios, fanny packs, or backpacks;

o watches with set alarms (turn off alarms);

o cameras, tape recorders, calculators or computers;

o pagers, electronic transmitting devices or telephones;

o bound or loose-leaf reference materials and notes;

o dictionary, thesaurus, or other spelling aids;

o canisters of mace, pepper spray or other personal defense items;

o containers of food and/or drink;

o tobacco products.

o Local anesthesia and/or syringe

NOTE: Unauthorized supplies, those NOT listed in this Candidate Information Booklet, will be subject to removal by the Department’s representative at the examination site. These include, but are not limited to the following:


Appendices

ULTRASONIC INSTRUMENT CONNECTIONS

PROGRESS FORM

TREATMENT SELECTION WORKSHEET

PATIENT’S HEALTH HISTORY FORM

PATIENT DISCLOSURE FORM

POST-EXAMINATION REVIEW REQUEST FORM

ADDRESS CHANGE FORM

CONTACT INFORMATION


ULTRASONIC INSTRUMENTS

If you do not have the correct part number, you cannot use ultrasonics. No candidate is allowed to share ultrasonics with another candidate in your session.

University of Florida provides Cavitron SPS ultrasonic requiring 30K inserts. Miami-Dade College provides Dentsply Ultrasonic Model 3000 requiring 30K inserts. Palm Beach State College DOES NOT provide ultrasonic equipment. Candidates wanting to

use ultrasonics MUST provide their own equipment.

HANDPIECE CONNECTION DIAGRAMS

University of Florida, Palm Beach State College, and

Miami-Dade College


NOT USED

NOT USED

DRIVE AIR

EXHAUST AIR

ACTUAL SIZE

SLOW SPEED HANDPIECE HOSE CONNECTION

ULTRASONIC SYSTEM CONNECTION

Palm Beach State College


UNIVERSITY OF FLORIDA

Cavitron SPS Ultrasonic Scaler Description


Cavitron 30K Ultrasonic Inserts for University of Florida and Miami-Dade College.

(Handpiece and Insert tips must be provided by the candidate)






Cubicle #:

Place barcode label above. If you do not have a barcode label, write in the corresponding numbers from your ID card on the lines above.

Patient’s name__________________________________________________________ Date Form Completed _____/_____/_____Birthdate _____/_____/_____ Weight _________ Blood Pressure ____________ Date/Time Taken _______________________

(Required – Must Be Taken Day of Examination)

INSTRUCTIONS TO THE PATIENT: Answer the following questions as completely and accurately as possible appropriate.Are you under the care of a physician at this time? . All information is CONFIDENTIAL. Please circle “yes” or “no” to all questions, and write in your answers as YES NOIf yes, for what condition? __________________________________________________________________________________The name and address of my physician is:______________________________________________________________________My last physical examination was on__________________________________________________________________________Has a physician treated you in the past six months? YES NOIf yes, for what condition? __________________________________________________________________________________Have you been hospitalized or have a serious illness within the last five years? YES NOIf yes, please specify:______________________________________________________________________________________Are you allergic or had any adverse reaction to any medicines, drugs, local anesthetics, LATEX or other substances? YES NOIf yes, please specify:______________________________________________________________________________________Do you have or have you had any of the following diseases/problems?

A. Abnormal bleeding, bruise easily or require blood transfusion…………...……………… YES NO Q. Artificial/Prosthetic heart valves………..… YES NO

B. Angina/Chest pain………………..……….. YES NO R. Valve damage following heart transplant.... YES NOC. Asthma/Lung/Respiratory condition……… YES NO S. Congenital heart disease………………….. YES NOD. Diabetes……………………………………. YES NO T. Infective endocarditis……………………... YES NOE. Emotional/Mental health disorder….……... YES NO U. Heart murmur……………………………... YES NOF. Epilepsy/Seizures/Convulsions……………. YES NO V. Mitral valve prolapse……………………... YES NOG. Hepatitis/Jaundice/Cirrhosis, Liver disease.. YES NO W. Rheumatic heart disease…………………... YES NOH. High blood pressure………………………. YES NO X. Congestive heart failure…………………... YES NOI. HIV positive/AIDS…….………………….. YES NO Y. Pacemaker ………………………………... YES NOJ. Hives or skin rash………………………….. YES NO Z. Cardiovascular (heart) disease, K. Kidney/Renal disease……………………... YES NO Arteriosclerosis/Coronary occlusion……... YES NOL. Sexually Transmitted Disease(s)….……….. YES NO AA. Cancer/Chemo/Radiation therapy………… YES NOM. Stomach ulcers……………………………. YES NO BB. Immune suppression or deficiency….......... YES NON. Thyroid disease……………………………. YES NO CC. Heart attack Date:_____________ YES NOO. Tuberculosis……………………….………. YES NO DD. Heart surgery Date:_____________ YES NOP. Artificial/Prosthetic joint replacement…….. YES NO EE. Stroke Date:_____________ YES NO

Have you had surgery or x-ray treatment for a tumor, growth or other condition of your head or neck? YES NO If yes, please list: __________________________________________________________________________________________

Do you have any other diseases, conditions, or problems not listed above? If yes, please explain: YES NO ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Medical

History

Please explain all “YES” answers to Questions # 4 - 9

Any item on the Medical History with a “YES” response, in questions #4-9 could require a Medical Clearance from a licensed physician if the explanation section indicated the possibility of a significant systemic condition that could affect the patient’s suitability for elective dental treatment during the examination. The Medical Clearance must include the physician’s name, address, and phone number.Are you taking or have you ever taken any of the following medications for any type of cancer, osteoporosis or bone loss due to aging, Paget’s Disease, or multiple myeloma? YES NO

If yes, please check the appropriate medication below:

Orally Administered Bisphosphonates Alendronate (Fosamax®) Risedronate (Actonel®)

Ibandronate (Boniva®) Tiludronate (Skelid®)

Olpadronte Other

Etidronate (Didronel® or Didrocal® or CO Etidronate® or Gen-Etidronate®)

IV Administered Bisphosphonates Clodronate (Bonefos® or Clasteon® or Ostac®)

Neridromate (Nerixia®)

Zoledronic acid (Zometa® or Aclasta®)

Other

Pamidronate (Aredia®)

Reclast® - used as a once per year dose for osteoporosis

(This list of Bisphosphonate medications should not be considered complete as new drugs are continually being developed)

Have you ever taken appetite suppressant drugs such as Dexfluramine, Fenfluramine, PhenFen, Pondimin, Redux? YES NO If yes, please list: _________________________________________________________________________________________

Please list any premedication, medications, pills, or drugs with dosage which you are taking both prescription and nonprescription (Must be completed the DAY OF THE EXAMINATION)

WOMEN ONLY: Are you pregnant? YES NO If yes, when is your expected due date?

________________________________________________________________________

Have you been rejected as a patient during any portion of the dental examination? YES NO

I certify that I have read and understand the above. I acknowledge that I have answered these questions accurately and completely. I will not hold the testing agency responsible for any action taken or not taken because of errors I may have made when completing this form.

PATIENT SIGNATURE: __________________________________________ DATE SIGNED: ___________________

Candidate’s initials acknowledging review of the above information:


FLORIDA DENTAL HYGIENE CLINICAL EXAMINATION

Candidate Number:

Examination Date:

IMPORTANT: Read carefully; this statement may affect your legal rights.

PATIENT DISCLOSURE STATEMENT AND EXPRESS ASSUMPTION OF RISKThe candidate treating you during this examination is not licensed in Florida at this time, but is applying for licensure to practice dental hygiene. However, neither the Department of Health nor the Board of Dentistry, its agents or other personnel, have any knowledge of the candidate's skill or competence, nor do they make representations as to the candidate's competence or skill. The Department, its employees, or its agents cannot and shall not assume any responsibility or liability for treatment during the course of the examination, or for any omissions or acts of negligence of any sort whatsoever, committed by the candidate. In addition, the Department assumes no duty or responsibility of any nature whatsoever to notify patients of poor work done by a candidate. It is expressly understood that it is your responsibility to have such work checked by a licensed dentist in order to determine that it is satisfactory.

ANY ARRANGEMENTS FOR YOU SERVING AS A PATIENT, FINANCIAL OR OTHERWISE, ARE BETWEEN YOU AND THE EXAMINATION CANDIDATE.PLEASE NOTE: Patients cannot be dentists, dental students, dental hygienists, dental hygiene students, or dental assistants.

IMPORTANT!!!! LIMITATION OF LIABILITY

By my signature below, I verify and agree that I have read and understood fully the above PATIENT DISCLOSURE AND EXPRESS ASSUMPTION OF RISK STATEMENT. I agree, and release the State of Florida, Department of Health, the Board of Dentistry, its employees and or agents from any and all responsibility or liability of any nature whatsoever for any acts of negligence, either by omission or commission, which are committed by the candidate during the course of this examination, and any damages or injuries I suffer as a result of my participation. I verify that I am not a dentist, dental student, dental hygienist, dental hygiene student or dental assistant.

PATIENTS NAME (PRINT):

ADDRESS: street city state zip code

SEX: MALE FEMALE AGE: TELEPHONE: ( )

Date of last physical examination:

Physician’s Name and Address:

SIGNATURE: Date:


DEPARTMENT OF HEALTH

BUREAU OF OPERATIONS, TESTING SERVICESPOST-EXAMINATION REVIEW REQUEST FORM

If you wish to request a post-examination review, please complete this form and enclose the appropriate fee. This request must be postmarked within 21 days from the date that Official Scores are released on the Testing Services Website

Return this form and check to:

ATTN: REVIEW COORDINATOR Department of Health Bureau of Operations, Testing Services

4052 Bald Cypress Way, BIN #C-90 Tallahassee, FL 32399-3290(850) 245-4252

NAME:_______________________________

ADDRESS:_______________________________

CITY/STATE:_______________________________

ZIP CODE:_______________________________

TELEPHONE: (____) (home) (____) (work)

PROFESSION: DENTAL HYGIENE_____

EXAMINATION DATE:________________________

*SOCIAL SECURITY NUMBER:_______________________

CANDIDATE NUMBER:________________________

REQUEST: ___ Clinical $ 100.00

________________________________ Candidate's Signature

The fee for review is non-refundable.

*Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal Statute. In this instance, social security numbers are mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 456.004(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D Child Support Agency to assure compliance with child support obligations. Social Security Numbers must also be recorded on all Professional and Occupational License


applications and will be used for licensee identification Pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act Of 1996 (Welfare Reform Act), 104 PUB.L. 193, SEC.317


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Please fill out the change of address form below and fax or mail to:

Department of HealthDivision of Medical Quality AssuranceBoard of Dentistry 4052 Bald Cypress Way, BIN #C-08Tallahassee, Florida 32399-3290Fax (850) 921-5389

ADDRESS CHANGE FORM

DENTAL HYGIENE

Please type or print in the appropriate spaces below if you have a change of address correction.

NAME:________________________________________________________________ EXAMINATION DATE:_________________________________________________

CANDIDATE NUMBER:_________________________________________________

PHONE NUMBERS:_____________________________________________________ Area Code/Number Area Code/Number

OLD ADDRESS:_________________________________________________________

_________________________________________________________

NEW ADDRESS:________________________________________________________

________________________________________________________

SIGNATURE:___________________________________________________________

NOTE: If your name has changed, please use your prior name on this form and contact the Board Office for name change or name correction information.




CONTACT INFORMATION

Application Policies

Scheduling

Re-examination

Fees

North East Regional Board of Dental Examiners, Inc.8484 Georgia Avenue, Suite 900Silver Spring, MD 20910301-563-3300301-563-3307 Fax

Application Policies

Re-examination

Name Changes

Change of Address

License Information

Fees

Department of HealthDivision of Medical Quality AssuranceBoard of Dentistry 4052 Bald Cypress Way, BIN #C-08Tallahassee, Florida 32399-3258(850) 245-4474email: [email protected]

www.doh.state.fl.us/mqa/dentistry

Scheduling

Grade Notification

Post-examination Review

Special Testing Accommodations

Department of HealthDivision of Medical Quality AssuranceTesting Services4052 Bald Cypress Way, BIN #C-90Tallahassee, Florida 32399-3290(850) 245-4252email: [email protected]

http://www.doh.state.fl.us/mqa/Exam/

Hearings

Agency ClerkDepartment of HealthOffice of the General Counsel4052 Bald Cypress Way, Bin A-02Tallahassee, FL 32399-1703email: [email protected]

Hotels Directions to Site

Please contact the Chamber of Commerce

IN THE CITY WHERE YOUR EXAMINATION IS SCHEDULED.

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