Certified Dental Assistant

Dental Assisting National Board, Inc.444 N. Michigan Ave., Suite 900, Chicago, IL 60611-3985

1-800-367-3262 Fax: 312-642-8507 Email: [email protected]

CDA

DANB accepts 2015 exam applications through Dec. 31, 2015.

DANBs 2015 Certifi ed Dental Assistant (CDA) exam application packet includes applications for the following exams:

Certifi ed Dental Assistant (CDA) GC, RHS and ICE component exams taken in the same test administration

General Chairside Assisting (GC) Radiation Health and Safety (RHS) Infection Control (ICE) RHS/ICE

RHS and ICE exams taken in the same test administration

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2 634.2 CDA 2015 Application Packet

Welcome. Congratulations on taking the fi rst step toward earning DANB Certifi ed Dental Assistant (CDA) certifi cation. This application packet includes the exam applications for the CDA exam and the three component exams that make up the CDA exam: Radiation Health and Safety (RHS), Infection Control (ICE) and General Chairside Assisting (GC). Candidates may take the CDA exam (RHS, GC and ICE), take the RHS and ICE exams at the same test administration (RHS/ICE), or take and pass the component exams separately within a fi ve-year period to earn certifi cation.

There are no eligibility requirements to take the RHS and ICE exams. After passing the RHS and ICE exams, a candidate receives a certifi cate of knowledge-based competency for each exam passed. The RHS exam is recognized or required in 21 states and the District of Columbia to meet radiography requirements. The CDA exam is recognized or required in 31 states and the District of Columbia for either radiography or for performing expanded functions. Currently, a total of 38 states, the District of Columbia, the U.S. Air Force and the Department of Veterans Affairs recognize or require DANB exams for dental assisting practice.

There are eligibility requirements to take the GC or CDA exam. A candidate must be eligible under one of three pathways. Read pages 12-13 to determine which pathway you will be eligible for and the documentation necessary for each.

Please be sure to sign and date the application, answer the background information questions, attach the proper documentation and include the payment. If you have any questions, please contact DANBs Client Service Representatives at 1-800-367-3262. DANB is here to help you through the process of earning DANB certifi cation.

There are currently more than 36,000 proud dental professionals who maintain DANB certifi cation! I wish you the best as you advance in the dental assisting profession.

Sincerely,

Cynthia C. Durley, M.Ed., MBA DANB Executive Director

2015 Dental Assisting National Board, Inc. The DANB logo is a registered trademark of the Dental Assisting National Board, Inc. (DANB). CDA, COA, CRFDA, CPFDA,CDPMA, COMSA, DANB, and Dental Assisting National Board are registered certifi cation marks of DANB. RHS, ICE, and Measuring Dental Assisting Excellence are registered service marks of DANB. CERTIFIED DENTAL ASSISTANT and NELDA are certifi cation marks of DANB. Mark of Dental Assisting Excellence is a service mark of DANB. Use of these marks is strictly prohibited, except as provided in the Usage Guidelines for DANB Trademarks, without the express written permission of DANB.

DANB is a member of the Institute for Credentialing Excellence. The National Commission for Certifying Agencies (NCCA), an Institute for Credentialing Excellence commission with responsibility for accrediting certifi cation programs, has evaluated DANB national certifi cation programs (CDA and COA), including DANB component exams (RHS, ICE, GC and OA), and fi nds that DANB programs meet NCCAs highest standards, thus helping to assure validity, reliability and objectivity in the testing process. DANB Executive Director Cindy Durley, M.Ed., MBA, completed a six-year term on the NCCA (Chair in 2003 and 2004) and fi ve years as an Institute for Credential-ing Excellence Board Director, serving as President in 2006. DANB Director of Testing and Measurement Johnna Gueorguieva, Ph.D., began her fi rst term as an Institute for Credentialing Excellence Board Director in 2013.

3634.2 CDA 2015 Application Packet

After the Exam 8 Name/Address Changes DANB Communications Hand Scoring Offi cial Exam Results Duplicate Exam Results Duplicate Certifi cates Retaking a Failed Exam Release of Exam Results Verifi cation of Certifi cates and Certifi cation Conditional Certifi cates and Offi cial Exam Results Appealing a Decision Application Statements 10

Background Information Questions 11 CDA/GC Exam Eligibility Pathways 12

CDA/GC Exam Application 14

Employer Work Experience Statement 15

RHS and ICE Exam Application 16

Exam Study Help and Reference Materials 17

Appendix A: 18CODA-Accredited Dental Assisting Programs

Appendix B: 19New Jersey-Approved Radiography Programs

Appendix C: 20Maryland-Approved Radiography Programs

About DANB 4

Applying for a DANB Exam 5 Exam Prerequisites Submitting an Exam Application Payment Instructions Background Information Policy Military Discount Returned Checks Incomplete Exam Applications Duplicate Exam Application Policy Group Testing Candidates With Disabilities DANBs Nondiscrimination Policy Retaking a Passed Exam

Scheduling a DANB Exam 6 Receiving the Test Admission Notice The 60-Day Testing Window Scheduling an Exam Appointment Exam Appointment Confi rmation Rescheduling an Exam Appointment Requesting a New Testing Window Requesting a New Testing Window Due to a Missed

Exam Appointment Requesting a New Testing Window Due to an Emer-

gency Canceling a Testing Window for a Partial Refund When Pearson VUE Cancels an Exam Appointment

Taking a DANB Exam 7 What to Bring to the Test Center Test Center Environment Candidate Behavior Before, During and After an Exam

Appointment Exam Integrity

Table of Contents

1. Candidate mails/faxes exam application, documentation and fees to DANB.

2. DANB processes candidate exam application.

3. If the application is accepted as complete, DANB mails candidate a Test Admission Notice.

4. Candidate schedules location, date and time of exam with testing vendor Pearson VUE.

5. Candidate sits for the DANB exam. A preliminary pass/fail exam result will be provided after completing the exam.

6. DANB mails candidate offi cial exam results. Certifi cates of knowledge-based compe-tency will be mailed upon passing the RHS and ICE exams. A CDA certifi cate will be mailed if all three component exams are passed.

3-4 week processing/mailing time

60-day window to schedule and take exam

2-3 weeks from exam date

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Testing with DANB: An Overview


DANBs MissionDANB is a nonprofi t organization. DANBs mission is to pro-mote the public good by providing credentialing services to the dental community.

We accomplish and measure the success of this mission through the creation of valid dental assisting exams; re-certifi cation requirement integrity; and valuable, visible and accessible DANB exams, certifi cates of knowledge-based competency and certifi cations.

We also provide testing services to the oral healthcare com-munity, and information services and resources related to dental assisting credentialing to support DANBs mission. In order to accomplish these critical outcomes, DANB is committed to a properly governed, fi nancially secure and administratively sound organization.

The purpose of the CDA exam is to ensure that dental assis-tants demonstrate entry-level knowledge-based competency regarding tasks important to the health and safety of patients and oral healthcare workers alike. Earning CDA certifi cation demonstrates that the individual meets the national standard for knowledge in general chairside assisting, radiation health and safety, and infection control.

DANB Certifi cationsDANB offers four national certifi cations: Certifi ed Dental Assistant CDA Certifi ed Orthodontic Assistant COA Certifi ed Preventive Functions Dental Assistant CPFDA Certifi ed Restorative Functions Dental Assistant CRFDA

In addition to these national certifi cations, DANB also offers the following certifi cates of knowledge-based competency, which allow a dental assistant to demonstrate knowledge in: Radiation Health and Safety (RHS) Infection Control (ICE) Coronal Polish (CP) Sealants (SE) Topical Anesthetic (TA) Topical Fluoride (TF) Anatomy, Morphology and Physiology (AMP) Impressions (IM) Temporaries (TMP) Isolation (IS)

Information and applications for COA, CPFDA and CRFDA ex-ams can be found in separate DANB exam application packets. Visit www.danb.org or call 1-800-367-3262.

*Each states dental board implements regulations and estab-lishes rules for delegating legally allowable duties to dental assistants. Passing one or more of the CDA component exams or earning CDA certifi cation only conveys authority to perform these duties in those states that recognize these exams or this certifi cation as meeting state dental assisting requirements. This information can be found at www.danb.org/Meet-State-Requirements.aspx.

About DANBSince its inception in 1948, the Dental Assisting National Board, Inc. (DANB) has worked within and with the support of the dental community. The American Dental Associa-tion recognizes DANB as the national certifi cation board for dental assistants.

The following organizations assist DANB in developing its dental assisting exams by recommending subject matter experts to DANBs exam committees: American Board of Oral and Maxillofacial Radiology American Dental Association Academy of General Dentistry American Association of Orthodontists Organization for Safety, Asepsis and Prevention American Academy of Oral and Maxillofacial Radiology

DANBs nine-member Board of Directors is elected by DANB from a slate of candidates nominated by: American Association of Dental Boards American Dental Education Association American Dental Assistants Association American Dental Association DANB certifi cants The public

Recognition of DANBs CDA ExamDANBs CDA exam is recognized or required in 31 states, plus the District of Columbia. DANBs CDA exam is recog-nized or required to perform expanded functions* in Arkan-sas, Georgia, Idaho, Illinois, Iowa, Maine, Maryland, Massa-chusetts, Minnesota, Missouri, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oregon, Rhode Island, South Dakota, Vermont, Virginia and Washington.

Recognition of DANBs RHS ExamDANBs RHS exam is recognized or required in 21 states, plus the District of Columbia, and meets state radiography requirements in Arizona, Colorado, Connecticut, Delaware, Indiana, Iowa, Kentucky, Maine, Maryland, Massachusetts, Montana, New Hampshire, New Jersey, New Mexico, North Dakota, Oregon, Pennsylvania, South Carolina, Utah, Vir-ginia, Wyoming and the District of Columbia.

Recognition of DANBs ICE ExamDANBs ICE exam is one component of the CDA exam and meets state requirements for infection control* in Iowa, New York and North Dakota.

U.S. Military and Federal Agencies RecognitionDANBs CDA exam and RHS certifi cate of knowledge-based competency meet the Department of Veterans Affairs re-quirement for expanded duties dental assistant designation. The Indian Health Services and all branches of the U.S. Military encourage DANB certifi cation. DANBs CDA exam is approved for the GIs-to-Jobs program under the Mont-gomery Bill.

Dental Assisting National Board, Inc.


Exam PrerequisitesThe CDA exam is made up of three component exams: The CDA exam is made up of three component exams: RHS, ICE and GC. To earn CDA certifi cation, a candidate RHS, ICE and GC. To earn CDA certifi cation, a candidate must pass all three component exams within a fi ve-year pe-must pass all three component exams within a fi ve-year pe-riod. The CDA component exams may be taken together or riod. The CDA component exams may be taken together or separately. There are no eligibility requirements to take the separately. There are no eligibility requirements to take the RHS and ICE component exams. The candidate must meet RHS and ICE component exams. The candidate must meet eligibility requirements to qualify to take the CDA exam or the eligibility requirements to qualify to take the CDA exam or the GC component exam. A candidate must qualify under one of GC component exam. A candidate must qualify under one of three pathways (see pages 12-13).three pathways (see pages 12-13).

Submitting an Exam ApplicationExam applications can be mailed or faxed to DANB. The candi-date should read this packet carefully to ensure the completed application is submitted with all required documents and fees.

Signing and dating the application is required. By sign-ing and dating the application, the candidate affi rms that the application and documentation are accurate and that the candidate agrees to abide by all applicable DANB policies described in this packet, including the Application Statements on page 10. The signature allows DANB to release exam results to state regulatory agencies. Payment InstructionsDANB accepts payment by check, money order or credit card (Visa, MasterCard, American Express or Discover). Check or money order payments must be payable to DANB in U.S. dollars and written in English. The application is a contract to test, and the check or credit card authorization is the contract to pay. The candidate should put his/her name on the check.

Background Information PolicyDANB national exam applications contain three background information questions that all exam candidates must answer. For details, see the Background Information Policy and Ques-tions section (see page 11).

Military DiscountSee the exam applications for active military personnel re-duced exam fees. To receive the reduced fee, the candidate must submit a letter from the commanding offi cer or an active military email address (this email address will be verifi ed by DANB upon approval of application). If a letter is provided, it must verify the candidates name, rank, Social Security number, station (location) and estimated date of separation.

If documentation of active duty is not submitted, the appli-cation is considered incomplete and will be returned to the sender. DANB will issue a refund within 30 days of notice of the incomplete application, minus the $50 nonrefundable application fee. Military personnel may schedule a DANB exam at authorized Pearson VUE on-base military test cen-ters. For on-base military test center locations, visit www.vue.com/danb.

Returned ChecksIf a candidate applies for an exam with a check that is returned by the bank for any reason (including but not limited to nonsuf-

fi cient funds, stop payment, closed account or refer to maker), DANB will assess a $25 nonsuffi cient funds (NSF) fee to the candidates account and notify the candidate. The candidate will not be allowed to take the exam until a cashiers check or money order for the full application and exam fee plus the $25 NSF fee has been received. If full payment has not been received within 30 days, the application will be null and void and the candidates account will remain on fi nance hold. The candidate must pay $75 (the $25 NSF fee and $50 nonrefund-able application fee) before DANB will remove the fi nance hold and process any exam application. No new business will be al-lowed for the candidate until the fi nance hold has been removed.

Incomplete Exam ApplicationsThe candidate is responsible for submitting a complete exam application. Incomplete applications are returned to the can-didate, and a letter indicating the reasons for the incomplete application will be sent to the candidate and the payer (if differ-ent). A refund for the exam fee, minus the $50 nonrefundable application fee, will be sent within 30 days of notice of the incomplete application. Refunds will be made only to the payer. An exam application is considered incomplete for reasons including but not limited to: Missing information (e.g., candidate and/or payment

information, background information questions) Appropriate documentation is not enclosed No date or signature Insuffi cient payment Expired exam application

Duplicate Exam Application PolicyA candidate may submit exam applications to take different component exams at any time. However, if two applications are received for the same exam, both completed applications will be accepted, and duplicate payments will be returned, minus the $50 nonrefundable application fee, within 30 days, after the payment clears.

Group TestingGroups of four or more candidates may request to take any DANB exams on the same day, at or around the same time. Download the Group Testing Form from www.danb.org or contact DANB at 1-800-367-3262 with questions.

Candidates With DisabilitiesDANB exams are designed to provide an equal opportunity for each candidate to demonstrate his/her knowledge-based competency. The exam will be administered to best ensure that it accurately refl ects a candidates aptitude or achieve-ment levels intended to be measured, rather than refl ecting a candidates impaired sensory, manual or speaking skills except where those skills are factors the exam purports to measure.

DANB adheres to the provisions outlined in the Americans with Disabilities Act. In accordance with this act, DANB will make every reasonable effort to offer the exams in a manner that is accessible to people with disabilities. If auxiliary aids or alternative arrangements are required, DANB will attempt to

Applying for a DANB Exam


Applying for a DANB Exam

Scheduling a DANB Exam

Receiving the Test Admission NoticeDANB will send the candidate a Test Admission Notice within three to four weeks of receiving the completed exam applica-tion. The Test Admission Notice confi rms that the candidate is eligible to take the exam and includes instructions to schedule the exam appointment. The candidate must check the Test Admission Notice for any of the following errors and report them to DANB immediately at 1-800-367-3262: The exam the candidate registered for is not the one listed The candidates name is spelled incorrectly The candidates ID refl ects a different name than the one

used to register to test (e.g., married, maiden, hyphen-ated, mothers last name)

The name on the Test Admission Notice must match the ID that the candidate will bring to the test center. The middle name does not need to be spelled out, but the initial must match (e.g., M on the ID and Mary on the Test Admission Notice is acceptable and vice versa). The candidate will be turned away from testing if the name on the ID does not match the Test Admission Notice. The candidate would need to reap-ply; see the Request a New Testing Window Due to a Missed Exam section in this packet for details.

The 60-Day Testing WindowThe candidate must take the exam within the 60-day window listed on the Test Admission Notice. Candidates who submit a CPR card that expires before the 60-day window ends will be given a shortened window based on the CPR expiration date.

Scheduling an Exam AppointmentThe candidate should schedule the exam appointment as soon as he/she receives the Test Admission Notice. The Test Admission Notice includes instructions to schedule the exam

appointment at a Pearson VUE location. To fi nd the nearest testing center, visit www.vue.com/danb. Appointments are scheduled on a fi rst-come, fi rst-served basis. Test centers may have limited availability. Changes to test centers may occur without notice. DANB cannot guarantee the availability of specifi c test center locations, dates or times.

Exam Appointment Confi rmationAfter the candidate schedules the exam appointment, he/she will receive a confi rmation via email (if the candidates email address was included on the exam application) or regular mail from Pearson VUE. Candidates should open and read all email and mail from Pearson VUE. There will be important information regarding the appointment.

Rescheduling an Exam AppointmentThe candidate may reschedule an exam appointment or extend the 60-day testing window. Regardless who paid for an exam, only the candidate may reschedule an exam ap-pointment. To reschedule an exam appointment within the 60-day window, the candidate must contact Pearson VUE. The candidate may reschedule an exam appointment up to 24 hours before his/her scheduled exam start time at no additional fee. See the Test Admission Notice for Pearson VUE contact information.

Requesting a New Testing WindowIf a candidate cannot schedule or reschedule an exam appoint-ment before the end of his/her 60-day testing window and would like to request a new testing window, he/she must complete both steps below:STEP 1: Cancel the exam appointment: If an exam appoint-ment has been scheduled, the candidate must cancel his/her appointment with Pearson VUE at least 24 hours before

make the necessary provisions, unless providing such would fundamentally alter the measurement of knowledge the exam is intended to test, would result in undue burden, or would provide an unfair advantage to the disabled candidate.To allow suffi cient time to make the necessary arrangements for modifi cations or auxiliary aids, the candidate must submit the Reasonable Accommodations Request forms (found at www.danb.org) with the required documentation and exam applica-tion, specifying exactly what aid or modifi cation is requested by a physician or psychologist. DANB will only accept the forms found at www.danb.org. DANB reserves the right to authorize the use of auxiliary aids or modifi cations in such a way as to maintain the exam integrity and security. DANB exams are administered only in the English language. Modifi cations will not be approved for a candidate who requests accommoda-tions because English is a second language. Contact DANB at 1-800-367-3262 with questions.

DANBs Nondiscrimination PolicyDANB does not discriminate in application, exam or certifi ca-tion activities on the basis of age, sex, gender identity, marital

status, race, color, religion, national origin, sexual orientation or disability.

Retaking a Passed ExamDANB certifi cants/candidates may take and pass DANB national certifi cation exams (CDA, COA, CPFDA, CRFDA) or component exams (ICE, RHS, GC, OA, CP, SE, TA, TF, AMP, IM, TMP, IS, RF) only once. These exams may be retaken if required for certifi cation (the exam was passed longer than fi ve years ago for CDA or COA component exams or three years ago for CPFDA or CRFDA component exams) or if di-rected to retake the component exam by DANB to recertify or reinstate certifi cation. Any certifi cant/candidate in violation of this policy will have his/her application denied and returned, and will be assessed the $50 nonrefundable application fee.

Any DANB candidate/certifi cant from the state of New Mexico who applies for the DANB RHS exam and has previously passed the RHS exam twice within the previous 12-month period will be in violation of this policy and will have his/her application denied and returned, and will be assessed the $50 nonrefund-able application fee.


What to Bring to the Test CenterBring the Test Admission Notice and one form of ID. The ID must be a currently valid, non-expired government-issued photo and signature-bearing ID, in roman characters. A drivers license, passport, military ID card, state ID card or U.S. government-issued permanent resident card are all acceptable. Test centers may use an electronic fi ngerprinting, palm vein and/or photo-graphic security system for identifi cation purposes only. Test centers may use a video/audio recording system to enhance exam security. The candidate must not bring any reference ma-terials or notes into any test center area. The candidate will be provided with an erasable noteboard and marker to use during the exam. No visitors or unauthorized individuals will be permit-ted in any test center area during testing sessions.

Test Center EnvironmentThe candidate will receive a tutorial before the exam to help the candidate feel comfortable with the computerized format. Time spent on the tutorial will not count as part of the exam

time period. The tutorial is not a practice test. The tutorial describes how to mark answers. There are no breaks during the exam. Candidates may be excused to visit the restroom, one at a time. During the absence, the exam time clock will continue to run. No additional time will be provided. There is no requirement for specifi c clothing, but it is a good idea to wear comfortable clothing in layers to adjust for minor fl uctuations in room temperature. It is also a good idea to wear soft-soled shoes to allow the candidate to leave his/her seat without disrupting others.

Candidate Behavior Before, During and After the Exam AppointmentThe behavior of each candidate taking an exam will be monitored. Improper behavior is not acceptable before, dur-ing or after an exam appointment. DANB seeks to ensure a fair and equitable testing experience for all individuals and to ensure the security and reliability of the process. DANBs

the scheduled exam start time. An exam appointment can be canceled online by visiting Pearson VUEs website, www.vue.com/danb, or by calling Pearson VUEs toll-free hot line during normal business hours. Failure to cancel an exam appointment will result in forfeiture of the full application/exam fees, and the application is null and void.

STEP 2: Request a new 60-day testing window: Mail or fax the Request a New Testing Window form to DANB within 60 days (pay $55 nonrefundable processing fee) or within 61-120 days (pay $110 nonrefundable processing fee) after the end of your original testing window. A candidate may request a new testing window up to two times. After the second request for a new testing window, a current exam application with any required documentation and full fees must be submitted.

Requesting a New Testing Window Due to a Missed Exam AppointmentIf the candidate arrives more than 15 minutes after an exam appointment start time, the candidate will be accommodated at the discretion of the test center administrator. If the administra-tor is unable to accommodate the candidate, or if the candidate does not take a scheduled exam because the candidate missed the appointment (for any reason except a valid emergency) or the candidate was denied entry, the candidate may reap-ply for the exam with a reduced fee using the Request a New Testing Window Due to a Missed Exam Appointment form within 60 days of the missed exam appointment (if received after 60 days, the candidate must reapply for the exam with the required documentation and pay the full fees). DANB will mail the form to eligible candidates. A candidate may request a new testing window due to a missed exam appointment one time. If another appointment is missed (for any reason except a valid emergency) or the exam is not taken within the new testing window, a current exam application with full fee must be submitted. Contact DANB at 1-800-367-3262 with questions. If the candidate has had an emergency, please see Request a New Testing Window Due to an Emergency below.

Requesting a New Testing Window Due to an Emer-gencyIf a candidate misses an exam appointment due to a personal emergency, the candidate must submit a Request to Receive a New Testing Window Due to an Emergency form explaining the emergency, including supporting documents. The candi-date must submit the request within 60 days of the sched-uled exam date. Download the form at www.danb.org. Call 1-800-367-3262 with any questions about what constitutes an emergency and appropriate supporting documentation. Approved requests will receive a new 60-day testing window at no additional fee.

Canceling a Testing Window for a Partial RefundSTEP 1: Cancel the exam appointment: If an exam appoint-ment has been scheduled, the candidate must cancel his/her appointment with Pearson VUE at least 24 hours before the scheduled exam start time. An exam appointment can be canceled online by visiting Pearson VUEs website, www.vue.com/danb, or by calling Pearson VUEs toll-free hotline during normal business hours. Failure to cancel a scheduled exam appointment will result in forfeiture of the full application/exam fees and the application is null and void.

STEP 2: Request to cancel the 60-day testing window: Mail or fax the Request to Cancel a Testing Window form so that it is received by DANB before the end of the 60-day testing window. DANB will issue a refund minus the $35 cancellation fee and $50 nonrefundable application fee (a total of $85 retained by DANB). DANB will issue the refund to the payer.

When Pearson VUE Cancels an Exam AppointmentIn the event of weather or other emergency, Pearson VUE will attempt to notify candidates by phone of a cancellation and will reschedule the exam appointment at no additional fee.

Scheduling a DANB Exam

Taking a DANB Exam


Taking a DANB ExamDisciplinary Policy & Procedures document, which is available at www.danb.org, contains examples of improper behavior.

Exam SecurityThe exam is confi dential. Any individual who removes or at-tempts to remove testing-related materials from the test center, or who attempts to memorize, distribute or otherwise misuse an exam, in whole or in part, in any form or by any means, verbal or written, electronic or mechanical, for any purpose, without the prior express written permission of DANB, will be subject to legal action. Any candidate or certifi cant who engages in improper behavior also will be subject to disciplinary action by DANB, which may include denial or revocation of certifi cation or recertifi cation. DANBs Disciplinary Policy & Procedures document is available at www.danb.org. The test center administrator will notify DANB of anyone who talks during the exam, gives or receives assistance, or otherwise engages or appears to engage in dishonest or improper behavior before, during or after the exam. Those candidates may be required to cease taking the exam and leave the test center.

The test center administrator will send a report to DANB regarding the incident. After reviewing a reported incident, DANB will determine whether there is reason to believe that a candidate has engaged in cheating or other improper behavior, or has otherwise violated the security of the exam. If DANB determines that the incident report is valid, DANB may, at its discretion, pursuant to the procedures set forth in DANBs Disciplinary Policy & Procedures, take disciplinary actions, including but not limited to the following: Order the candidate to retake the exam at a time and

place to be determined by DANB Invalidate or refuse to release the exam results of the

candidate

Deny the candidates current application for certifi cation Require the candidate to wait a specifi ed period of time

before reapplying to take the exam Revoke the candidates eligibility to sit for future exams Take a combination of any of the above actions or other

action that DANB may deem appropriate.

If a test center administrator allows a candidate to take an exam that the candidate is not registered for, those results will not be valid. The original application will be considered null and void, and the full application and exam fees will be forfeited. The candidate will be required to reapply with a new application, required documentation and payment of the full exam and application fees.

Exam IntegrityTo ensure a consistently high-quality testing program, each exam is routinely reviewed for reliability and validity. Each exam question is statistically analyzed and evaluated for performance. A small number of pretest questions appear on each DANB national exam. Pretest questions are new test items that DANB includes on each exam as a way to ensure they are accurate measures of candidate knowledge. Pretest questions are randomly distributed throughout the exam and are not counted in the fi nal exam results. Since the candidate will not know which items are pretest questions and which are not, the candidate should answer all exam questions to the best of his/her ability.

DANB exam committees, with fi nal DANB Board approval, establish passing standards (the minimum required to pass a particular DANB exam) using standard psychometric proce-dures for criterion-referenced exams. A candidate is expected to perform at or above the Board-established standard to pass each exam.

After the Exam

Name/Address ChangesThe candidate must notify DANB of address changes or any errors in the candidates name. Call 1-800-367-3262 or email [email protected]. A candidate must submit a Name Change Request form and required documentation to change a name with DANB. The form is available at www.danb.org.

DANB CommunicationsAll communications sent to and from DANB are DANBs prop-erty. DANB cannot guarantee that communications will remain confi dential; clients have no expectation of privacy with respect to items sent or received. DANB may disclose communications as necessary to comply with legal processes. DANB responds to phone and email messages within two business days.

Hand ScoringDANB will hand score an exam on request. The candidate must submit a Request for Hand Scoring of Exam Results form and a $50 hand scoring fee to DANB within 30 days after the date printed on the exam results received. The form is available at www.danb.org. Hand scoring results of the exam are completed within 30 days of a request. If the pass/

fail status is reversed as a result of the hand scoring, the $50 fee will be refunded.

Offi cial Exam ResultsThe candidate will receive preliminary results at the test cen-ter upon completing the exam. DANB presents exam results as a pass or fail. DANB provides sub-content performance ratings for candidates who receive a fail status, which pro-vide useful information regarding performance in each of the content areas on the exam. Sub-content results are rated as high priority or average priority. Sub-content performance ratings are a refl ection on how well a candidate did in a par-ticular content area of the exam and cannot be used in any way to determine overall passing status. Knowledge of an area of weakness is a useful tool to help plan for further study. The candidate is not considered to have passed or failed an exam until DANB generates and mails the offi cial exam re-sults. DANB will mail two copies of offi cial CDA exam results; one copy of offi cial RHS, ICE and GC exam results; and any earned certifi cates within two to three weeks after each exam administration. Offi cial exam results and certifi cates that are returned because of an undeliverable address will be held


After the Examfor 90 days. DANB will call the candidate to request a new mailing address. If DANB cannot reach the candidate and the 90-day period expires, DANB will destroy the original results. If the candidate contacts DANB with an address change after the 90-day period, DANB will release new results after the candidate submits a Request for Duplicate Exam Results form and/or a Request for a Duplicate Certifi cate form with a $25 fee for each request.

Duplicate Exam ResultsDuplicate exam results are available for exams taken within the last fi ve years. The candidate must submit a Request for Duplicate Exam Results form and the $25 fee for each offi cial exam result request. Offi cial exam results older than fi ve years are not available, although DANB will verify cer-tifi cations or certifi cates of knowledge-based competency earned more than fi ve years ago.

Duplicate Certifi catesDuplicate certifi cates are available for $25. CDA duplicate certifi cates may only be requested if the certifi cation wasearned on June 1, 1993, or later. Because DANB provides several opportunities for a candidate to correct errors, this $25 duplicate certifi cate fee also applies for any reprint of a certifi cate due to a spelling error. Download the Request forDuplicate Certifi cate form at www.danb.org.

Retaking a Failed ExamIf the candidate takes the CDA exam or the RHS/ICE exam but does not pass all of the component exams, the candidate only needs to reapply for the failed component exam(s) with a new application, required documentation and fees. DANB will issue any earned certifi cates of knowledge-based compe-tency. The candidate must pass all three component exams within a fi ve-year period to earn CDA certifi cation. State laws may require additional education after failed attempts. There is no limit on how many times the candidate may take a failed exam. Visit www.danb.org for more information.

Release of Exam ResultsExam pass/fail results will not be released to employers or any individuals other than the candidate, except on writ-ten request of the candidate. DANB releases offi cial exam results or credential verifi cations to some state regulatory agencies. DANB also releases aggregate results to program directors for candidates who are graduates from or students in the program directors dental assisting programs. If you work out of state, please fi ll in your work state on the appli-cation. Failure to include out of state work information could hinder meeting state requirements as your exam results will not be sent to the appropriate state regulatory agency.

Verifi cation of Certifi cates and Certifi cationDANB will verify DANB certifi cation, RHS and ICE exam pass/fail status and the effective date(s) of certifi cation over the phone to anyone on request, since these items are matters of public record and may be disclosed. The Candidate/Certifi -cant Request for Verifi cation form is available at www.danb.org. Only a candidate, certifi cant or employer may request

written credential verifi cation. DANB offers verifi cation on its website. See the Application Statements for more details.

Conditional Certifi cates and Offi cial Exam ResultsIn some cases, DANB may grant a conditional authoriza-tion to test to an exam candidate who answered yes to a background information question and is in the process of completing court or regulatory agency requirements. Not every person who answers yes to a background informa-tion question will be placed on conditional status. Condi-tional status will be offered to an exam candidate only in certain circumstances at DANBs discretion. A candidate who has been placed on conditional status will receive an offi cial exam result and, if earned, a certifi cate marked con-ditional. If a person is conditionally certifi ed or has received a conditional certifi cate of knowledge-based competency or offi cial exam results, this means that the certifi cation, certifi -cate and/or results will remain valid only if certain conditions are met in a timely manner. In many cases, the conditions will include fulfi llment of all obligations to a court of law or regulatory agency. Full details about conditional certifi cation and conditional certifi cates of knowledge-based compe-tency and offi cial exam results and related processes and procedures will be provided to each individual who is placed on conditional status by DANB.

Use of Certifi cation Marks and Maintaining Certifi cationCDA certifi cants may use the CDA mark after their names on a resume, business card, website, in a book or publica-tion, and in other print and electronic media. A CDA certifi cant may also display the mark on a nametag or uniform worn dur-ing the rendering or promoting of certifi ed services, and on a wall plaque present at the place where he/she renders or promotes the certifi ed services. If a certifi cant earned CDA certifi cation in the past but has not maintained certifi cation, he/she may not use the CDA mark. To remain certifi ed, DANB requires a minimum of 12 Continuing Dental Education (CDE) credits annually (for those who hold one DANB certifi ca-tion). The requirements enhance the continued competence of DANB certifi cants, and promote DANBs goal of lifelong professional learning and development for its certifi cants. In addition to the annual CDE requirement, each certifi cant is required to answer Background Information Questions, maintain DANB-accepted hands-on CPR, BLS or ACLS cer-tifi cation and pay the annual renewal fee. For more informa-tion, please go online to www.danb.org.

Appealing a DecisionIf a candidate wishes to appeal a DANB decision regard-ing eligibility, administrative or exam content issues, he/she may submit a Request for Reconsideration Under DANBsReview and Appeal Process form and a $25 appeal fee to DANBs Executive Director within 30 days of the date on the DANB correspondence that prompts the candidate to appeal (e.g., date on the letter indicating the candidates ap-plication was incomplete, date on candidates exam results). The policy governing requests for reconsideration is avail-able by contacting DANB at 1-800-367-3262.

10 634.2 CDA 2015 Application Packet Revised 10/1/12

1. I hereby apply to the Dental Assisting National Board, Inc. (DANB) for examination by DANB and issuance to me of a certifi cate, in accor-dance with and subject to the procedures and regulations of DANB. Under penalty of perjury, I declare that the information provided on my application is true. I have read and agree to the requirements and conditions set forth in the DANB application packet covering eligibility for and the administration of certifi cation exams, the certifi cation process, and DANB policies, including but not limited to the DANB Code of Professional Conduct. I agree to disqualifi cation from the exam, to denial of certifi cation, and to forfeiture and return to DANB of any certifi cate granted me by DANB, in the event that any of the answers or statements made by me in this application are false, or in the event that I violate any DANB rules or regulations. I authorize DANB to make whatever inquiries and investigations it deems necessary to verify my credentials or professional standing.

2. I hereby release DANB, its directors, offi cers, examiners and agents from any and all liability arising out of or in connection with any action or omission by any of them in connection with this application, the certifi cation process, any exam given by DANB, any scoring relating thereto, the failure to issue me a certifi cate, or any demand for forfeiture or return of such certifi cate, and I agree to indemnify DANB and said persons and hold them harmless from any lawsuit, complaint, claim, loss, damage, cost or expense, including attorneys fees, arising out of or in connection with said certifi cation activities. I UNDERSTAND THAT THE DECISION AS TO WHETHER I QUALIFY FOR A NATIONAL CERTIFICATION OR CERTIFICATE OF KNOWLEDGE-BASED COMPETENCY RESTS SOLELY AND EXCLUSIVELY WITH DANB AND THAT THE DECISION OF DANB IS FINAL. Notwithstanding the above, should I fi le suit against DANB, I agree that any such action shall be governed by and construed under the laws of the State of Illinois without regard to confl icts of law. I further agree that any such action shall be brought in the Circuit Court of Cook County in the State of Illinois, or the United States District Court for the Northern District of Illinois; I consent to the jurisdiction of such state and federal courts; and I agree that the venue of such courts is proper. I further agree that should I not prevail in any such action, DANB shall be entitled to all costs, including reasonable attorneys fees, incurred in connection with the litigation.

3. I understand that except as provided below, this application and any information or material received or generated by DANB in connection with this application or the exam process will be kept confi dential and will not be released unless I have authorized such release or the release is required by law. I understand that DANB will verify receipt of any DANB exam application and the date received, on request. I further understand and agree that DANB may also provide verifi cation to anyone by phone, by mail or on DANBs website regarding whether I hold any DANB certifi cations, including the Certifi ed Dental Assistant (CDA), Certifi ed Preventive Functions Dental Assistant (CPFDA), Certifi ed Restorative Functions Dental Assistant (CRFDA), Certifi ed Orthodontic Assistant (COA), Certifi ed Dental Practice Man-agement Administrator (CDPMA), or Certifi ed Oral and Maxillofacial Surgery Assistant (COMSA) certifi cations; any DANB certifi cates of knowledge-based competency, including Radiation Health and Safety (RHS), Infection Control (ICE), Coronal Polish (CP), Sealants (SE), Topical Anesthetic (TA), Topical Fluoride (TF), Anatomy, Morphology and Physiology (AMP), Impressions (IM), Temporaries (TMP), and Isolation (IS); and any state-specifi c certifi cates administered by DANB on behalf of a state regulatory body, including the Arizona Radio-logic Profi ciency certifi cate, Arizona Coronal Polishing certifi cate, Oregon Radiologic Profi ciency certifi cate, Oregon Expanded Functions Dental Assistant certifi cate and Oregon Expanded Functions Orthodontic Dental Assistant certifi cate. Phone and mail verifi cation will be provided to anyone upon request and will consist of oral or written confi rmation of whether I hold any of the DANB-administered credentials listed above and the effective dates for each credential. Online verifi cation through DANBs website may consist of online display of my name, the DANB-administered credentials I hold and dates earned, current DANB certifi cation status, and my city and state of residence. My full address will not be posted online by DANB. I further understand and agree that DANB may, from time to time, provide my name and address along with the names and addresses of certifi cants and those holding DANB certifi cates of knowledge-based competency to dentists interested in hiring a DANB individual from their area, and to providers of continuing education opportunities. I further understand that this consent will remain in effect unless and until I submit a written request to have this information omitted from release. I understand that if I want to opt out of the online verifi cation process, then I must submit a written request for omission of this information to the follow-ing address: DANB Communications Department, 444 N. Michigan Ave., Suite 900, Chicago, IL 60611.

4. I understand that by providing my email address on the application form, I am consenting to receive email messages from DANB and its affi liates related to their products and services or news affecting the dental assisting profession. I understand that DANB agrees not to provide my email address to any third party without my consent, and that I can request removal from DANBs email distribution list by follow-ing the directions contained in the Privacy Policy section of DANBs Terms and Conditions of Use of DANB.org, located at www.danb.org.

5. I authorize DANB to release my exam results to state regulatory agencies. Individuals cannot opt out of DANB release of exam results to state regulatory agencies. I also authorize DANB to use information from my application and exam(s) for statistical analysis, providing that any personal identifi cation is deleted.

6. I understand that I can be disqualifi ed from taking or continuing to sit for an exam, from receiving exam results and from obtaining certifi ca-tion if DANB determines through proctor observation, statistical analysis or any other means that I was engaged in collaborative, disruptive or other unacceptable behavior during the administration of or following the exam.

7. I understand that the content of all DANB exams is proprietary and strictly confi dential information. I hereby agree that I will not disclose, either directly or indirectly, any question or any part of any question from the exam to any person or entity. I understand that the unauthor-ized receipt, retention, possession, copying or disclosure of any DANB exam materials, including but not limited to the content of any exam question, before, during or after the exam may subject me to legal action. Such legal action may result in monetary damages and/or disciplinary action including voiding exam results and denial or revocation of certifi cation.

8. I understand that for each application submitted, DANB will process the appropriate payment. If I fail to show up for an exam for which I have applied, and there is no documented DANB-accepted emergency, and I failed to comply with DANB cancellation policies, I am still obligated to pay the full exam fee. I further understand that taking the exam and then revoking payment constitutes the wrongful use of DANB products and services and I may be subjected to legal action. I am obligated to pay for the exam whether I pass or fail. I agree not to dispute the exam fee. Passing candidates will not be eligible to retain their exam results if the exam fee is not paid in full.

Please read the following Application Statements carefully. The Application Statements apply to all DANB national exams. Candidates signature on the application indicates understanding and agreement to be legally bound by these statements.

Application Statements


Background Information Policy and Questions

Background Information PolicyDANB national exam applications contain three background information questions that all exam candidates must answer. These questions require the DANB national exam candidate to disclose if he/she has had any felony convictions within the last fi ve years or is currently serving a sentence for a felony conviction; has ever been disciplined by a regulatory, certifying or examination agency; has ever been investigated or dismissed by an educational institution for cheating or another ethical violation; or has ever been declared mentally incompetent by a court of law. DANB will review each response and make a determination, in consultation with legal counsel, on a case-by-case basis. DANB reserves the right, under extraordinary circumstances, to bring individuals for review under DANBs Disciplinary Policy & Procedures.

Background Information QuestionsThe candidate must answer each question in the box in the background information section on the exam application. Fail-ure to answer the background information questions will result in an incomplete application.

1. Is your answer yes to either of the following? In the last fi ve years, have you been convicted of, or pled guilty or no contest to, a felony or any crime punishable

by confi nement in a state or federal prison for any length of time? Are you currently serving a sentence of confi nement, home detention, parole, probation, or other court-ordered

supervision, or are you subject to a reporting requirement (e.g., sex offender or violent offender registry) in con-nection with a felony conviction, including for any conviction that occurred more than fi ve years ago?

It is not necessary to report misdemeanor convictions. If you are uncertain whether a conviction was for a felony or a misdemean-or, you must mark yes.

2. Have you ever been the subject of any of the following: Suspension, revocation, or voluntary surrender of your dental assisting license, registration, or other state-recog-

nized dental assisting credential? Suspension, revocation, or voluntary surrender of a license, registration, or other state-recognized credential in

any profession? Loss of authorization to practice dental assisting or any profession as an employee of the federal government? Loss of authorization to practice dental assisting or any profession in a jurisdiction that does not require registra-

tion, licensure, or other recognized employment credential? Disciplinary action by a professional regulatory board, certifying or examination agency, or other professional body? Investigation by or dismissal from an educational institution for cheating or any other ethical violation?

3. Have you ever been declared mentally incompetent by a court of law?

Documentation Required if a Candidate Answers YesIf a candidate answers yes to any background information question, he/she must attach a signed and dated personal statement describing the circumstances surrounding each occurrence, the offense or reason for the conviction or disciplin-ary action, the date of the adverse action, the penalties imposed, and the dates when penalties for each occurrence were or will be completed.

The candidate must also provide offi cial documentation related to each occurrence, as described in more detail below: For felony convictions (i.e., a yes answer to the fi rst question), documentation may include a true copy of every

police report, judgment of conviction, sentencing order and termination of probation order, if applicable; documents should show the offense underlying each conviction, the date of conviction, the penalties imposed by the court and evidence that all of the requirements imposed by the court were completed. Any person being held on criminal charg-es or serving a sentence of confi nement, including prison, jail, home detention, or an equivalent mode of confi nement, for any offense, must be fully released from confi nement before applying for and/or taking a DANB exam or before renewing or reinstating DANB certifi cation.

For regulatory, credentialing or educational disciplinary action (i.e., a yes answer to the second question), docu-mentation may include a true and offi cial statement from the disciplining agency or educational institution describing the offense and penalties imposed and, if applicable, providing evidence of completion or expiration of all penalties, including reinstatement of license or credential.

For a court declaration of mental incompetence (i.e., a yes answer to the third question), documentation may include true copies of all relevant court orders and related documents.


CDA and GC Exam Eligibility Pathways

CDA and GC Pathway I1. Graduation (or anticipated graduation) from a Com-

mission on Dental Accreditation (CODA)-accredited dental assisting or dental hygiene program or current Registered Dental Hygienist (RDH) license

Required DocumentationFor graduates: Enter the CODA-accredited program code number (see

pages 18-19) on the application.Enclose a photocopy of the candidates certifi cate of

completion/diploma or offi cial transcript (transcript may not be a copy). Document must show proof of program completion. A letter from a CODA-accredited dental assisting program on school letterhead indicating the candidates name and date of graduation, signed and dated by the program director, will also be accepted.

For students scheduled to graduate within 90 days after ap-plication to test: Submit an Intent to Graduate letter that must include:

Students name Date the program director anticipates the student will

complete the dental assisting program (must be dated within 90 days of anticipated graduation date)

Program directors signature and date signed Must be on school letterhead

Offi cial exam results and certifi cates will be held by DANB for all candidates who submit an Intent to Graduate letter as proof of anticipated graduation, until required proof of gradu-ation has been received by DANB. Once the exam is taken, the DANB Graduation Documentation for Pathway I form (available at www.danb.org) will be mailed to each candidate who submitted an Intent to Graduate letter. Program directors are required to notify DANB in writing should any student for whom this statement was provided fail to graduate. If a candidate fails to submit the required documentation within 90 days from the testing date, GC exam results will become invalid, and RHS and ICE exam results and certifi cates of knowledge-based competency will be mailed to the candidate, if applicable.

For Registered Dental Hygienists: Enclose a photocopy of the candidates RDH license (ac-

cepted from any state except Alabama). Must be current at the date of application and exam.

2. Current Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) from a DANB-accepted provider; must be current at the date of application and exam.

Required Documentationq Enclose front and back copy of a valid, DANB-accept-

ed hands-on CPR, BLS or ACLS card (see page 13).

CDA and GC Pathway II1. High school graduation or equivalent Required DocumentationFor high school eligibility in the U.S. and Canada:q Enclose a photocopy of the candidates high school

diploma, GED certifi cate or offi cial transcript (transcript may not be a copy) indicating graduation (high school or GED institution must be a recognized school in the U.S. education system), or offi cial state agency graduation verifi cation of high school graduation; or proof of college or postsecondary coursework at an institution accredited by a U.S. Department of Education-recognized agency. Offi cial documents must include a school seal, school stamp indicating the document is offi cial. For U.S. high school education verifi cation, contact the state board of education. Any cost of such independent verifi cation shall be the responsibility of the candidate. No other documen-tation will be considered.

For high school eligibility outside the U.S. and Canada: Enclose a photocopy of the candidates high school di-

ploma or a photocopy of transcript with graduation date or a photocopy of the postsecondary degree/college transcript and a photocopy of the document translation.

Enclose an offi cial equivalency report from an indepen-dent, DANB-accepted evaluator in a sealed envelope from the evaluator. If the equivalency report arrives with the application and is not in a sealed envelope from the evaluator, the application will be returned, minus the $50 nonrefundable application fee.

An international graduate must submit his/her education credentials for evaluation to one of these DANB-accepted providers: National Association of Credential Evalu-ation Services (www.naces.org) or the American As-sociation of Collegiate Registrars and Admissions Offi cers (ies.aacrao.org) at 202-296-3359, ext. 4600, or [email protected]. All costs shall be the responsibility of the candidate. DANB will return all original international documents to candidates.

2. Minimum of 3,500 hours work experience as a dental assistant, accrued over a period of at least two years to a maximum of four years; employment must be verifi ed by a licensed dentist.

Required Documentation q Enclose a completed Employer Work Experience State-

ment found on page 15. Dental assisting experience gained outside the United States/Canada may be used to qualify to take a DANB exam.

3. Current Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) from a DANB-accepted provider; must be cur-rent at the date of application and exam.

Required Documentationq Enclose front and back copy of a valid, DANB-accepted

hands-on CPR, BLS or ACLS card (see page 13).


CDA and GC PATHWAY III1. Status as a former DANB CDA certifi cant or

Graduation from a CODA-accredited D.D.S. or D.M.D. program orGraduation from a dental degree program outside the U.S. or Canada

Required DocumentationFor former DANB CDA Certifi cants:q Enter the candidates DANB certifi cation number on the

application. For DANB certifi cation number, call DANB at 1-800-367-3262.

For graduates of a CODA-accredited D.D.S. or D.M.D. pro-gram in the U.S. or Canada:q Enclose a photocopy of the candidates diploma, certifi -

cate of completion or dental license.

For graduates of a D.D.S. or D.M.D. program outside the U.S. and Canada: q Enclose a photocopy of the candidates dental school

transcript and the translation OR a photocopy of a di-ploma and the translation, OR a photocopy of a current dental license and the translation.

q All non-English language documents must be translat-ed into English and a copy of the document translation submitted with your application. Translation does not have to be offi cial.

2. Current Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS) from a DANB-accepted provider; must be current at the date of application and exam.

Required Documentationq Enclose front and back copy of a valid, DANB-accepted

hands-on CPR, BLS or ACLS card (see next column).

CDA and GC Exam Eligibility Pathways

CPR, BLS or ACLS: Required Documentation For All CDA/GC Exam Eligibility PathwaysCPR, BLS or ACLS must be current (not expired) at the time the candidate applies and takes the exam. A candidate who submits a CPR, BLS or ACLS card that expires before the 60-day testing window will be given a shortened window based on the CPR, BLS or ACLS expiration date.

Enclose a photocopy of the candidates current, signed CPR, BLS or ACLS card (front and back) from one of the organi-zations listed below. The card must be dated and signed or imprinted with the instructors name and also have the candi-dates name or signature on the card. The course must include CPR, and a hands-on exam must be taken. An exemption will be allowed if a candidate submits a letter from a physician verifying that the individual has a permanent disability that prevents achievement of accepted CPR.

DANB only accepts CPR, BLS or ACLS from the providers below, and only if the course included CPR and a hands-on exam is taken. CPR, BLS or ACLS from other providers will not be accepted, and exam applications will be returned as incomplete.

DANB-Accepted CPR, BLS and ACLS Providers American Environmental Health and Safety American Heart Association American Red Cross (card or certifi cate accepted) American Safety and Health Institute Canadian Red Cross Emergency Care and Safety Institute Emergency First Response Emergency Medical Training Associates Emergency University* EMS Safety Services Medic First Aid Military Training Network National Safety Council (Green Cross) ProCPR* Saudi Heart Association

* Not all courses include the hands-on exam, so check with the provider before taking the course to be sure it will be accepted by DANB.


2015 Certifi ed Dental Assistant (CDA) or General Chairside Assisting (GC) Exam

1. It is the responsibility of the candidate to ensure that this application is signed and dated, the background information questions are answered, and all required documentation and fees are included and submitted to DANB. Incomplete applications will be returned with a refund minus the $50 nonrefundable application fee.

2. Mail or fax completed application and supporting documents to DANB. Checks must include candidates name.

This 2015 application will be accepted through Dec. 31, 2015. After Dec. 31, 2015, download a 2016 application packet from www.danb.org.

I am a U.S. citizen. q Yes q No Non-U.S. citizens will be provided a temporary number by DANB in lieu of a Social Security #. I work in a state different than the one in which I reside. q Yes q No If yes, what state:_____ English is the language I speak at home. q Yes q No I work in a dental offi ce. q Yes q No I work in a dental offi ce that uses: q digital radiography q automatic processing q manual processing (check all that apply)

Candidate Information Must be fi lled out completely or application will be returned as incomplete.

Name (must match your ID exactly)_______________________________________________________________________________

Prior Name (if applicable)____________________________________ Email______________________________________________

Home Address___________________________________________ City________________________ State________Zip_________

Phone Numbers: Offi ce(___)_______________ Home(___)_______________ Cell(___)_______________ Fax(___)_______________

Last First Middle Name or Initial

(Please type or print with a pen.)

Candidates SS#

__ __ __-__ __ -__ __ __ __

Mail: DANB 444 N. Michigan Ave., Suite 900 Chicago, IL 60611 OR Fax: 312-642-8507 Questions? 1-800-367-3262 or www.danb.org Do not fax twice or you will be charged twice.

CDA exam (3605)GC exam (3635)

q Traditional candidate: q Employed in Maryland: q Active military personnel:

Candidates Name_________________________________________________ Candidates SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Payment Information Must be fi lled out completely or application will be returned as incomplete.

q Check/Money Order (payable to the Dental Assisting National Board, Inc. or DANB)q Credit Card Authorization (VISA, Mastercard, Discover & American Express accepted): Amount $_____________

Credit Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ CVV __ __ __ Expiration Date __ __/__ __

By signing, the cardholder acknowledges intent to register for the aforementioned DANB exam in the amount of the total shown hereon and agrees to perform the obligations set forth in the cardholders agreement with the issuer. Furthermore, the cardholder understands that the signature obtained at the exam administration shall be used to indicate receipt of purchase. A candidate who fails to show up for the exam for which he/she registered and has not canceled the exam as described in this packet is still required to pay for the exam. (See the Application Statements for further requirements.)

Cardholders Name___________________________________________ Cardholders Signature X_________________________________________

Cardholders Billing Address_______________________________________________ City________________________________________________

State__________________________ Zip _________________________ Daytime Phone number (_______)__________________________________

I hereby affi rm that my answers to all questions are true and correct, I have met all eligibility requirements, and I will comply with all DANB policies and procedures. I further affi rm that I have read and understood the Application Statements contained on page 10, and I intend to be legally bound by them. I understand that the $50 application fee is not refundable under any circumstances.

Signature X____________________________________________ Date X____________________________

Signature and Date Must be signed and dated or the application will be returned as incomplete.

Revised 10/1/12

Please indicate which exam you would like to take. Check only one box.

q CDA exam (GC, RHS, ICE exams taken together)

q GC exam only

Background Information All three questions in this section must be answered or application will be returned as incomplete.Read the questions in their entirety on page 11. Failure to answer all three questions will result in the application being returned as incomplete. If you checked Yes for any question, make sure to include required documentation.

1. Regarding felony convictions within the last fi ve years or sentences currently being served for felony convictions

No Yes

2. Regarding having ever been disciplined by a regulatory board, certifying or examination agency or educational institution

3. Regarding ever being declared mentally incompetent by a court of law

No Yes

No Yes

Complete documentation must be attached or application will be returned as incomplete. Select the eligibility pathway and provide the appropriate supporting information. Include CPR card copy (front and back) for all pathways.

Employed in MD or NJ ONLYState Approved School ID #

__ __ __ __ (see insert)

q Pathway I Program code ____________ (see Appendix A)q Pathway II Total dental assisting work experience _____/_____ (years/months) q Pathway III DANB CDA certifi cation # __ __ __ __ __ __

Eligibility Pathway Information Complete documentation must be attached or application will be returned as incomplete.

For offi ce use only. CDA (3605) GC (3635)

CDA exam fee: $375 GC only: $200CDA exam fee: $395 GC only: $200CDA exam fee: $350 GC only: $195


This form is part of the documentation required for CDA/GC application under Pathway II. Please see pages 12-13 for additional documentation required.

X __________________________________________________ X ______________________________ Signature of Licensed Dentist Date

3 Preliminary examination of patients (intraoral and extraoral)3 Charting teeth/completing treatment documentation3 Using diagnostic aids (such as radiographs and impressions for study models) 3 Taking and recording patients vital signs

3 Four-handed dentistry techniques 3 Preparation and understanding of armamentarium3 Performing and assisting with intraoral procedures 3 Managing patients3 Processes and procedures for the laboratory

3 Use, handling and characteristics of dental materials3 Providing oral health patient education3 Offi ce operations (inventory, ordering, equipment maintenance and legal) 3 Preventing/managing dental/medical emergencies

2015 Employer Work Experience Statement (CDA/GC ExamPathway II)This 2015 Employer Work Experience Statement will be accepted through Dec. 31, 2015.

Please print clearly with a pen. The form must be fi lled out completely or the application will be returned as incomplete.

Name of Dental Practice _______________________________________ Offi ce Phone ___________________________Address ______________________________________ City _______________________ State _____ Zip ___________Name of Licensed Dentist _______________________________________________ Lic # ________________________A licensed dentist (license will be verifi ed by DANB staff), from any country, can assess the work experience of a dental assistant in the country that the verifying dentist supervised/trained the dental assistant for whom he/she is completing a DANB Work Experience Statement.

Name of Exam Candidate (Assistant): __________________________________________________________________

I hereby attest that the above named candidate has worked a minimum of 3,500 hours as a dental assistant, accrued over at least two years and a maximum of four years. I am verifying all employment even if the candidate has worked for other dentists in prior years. Dates candidate has been in my employment: From __________________ To ___________________ include month and year include month and year

Dates of previous employment: From __________________ To ____________________ include month and year include month and year

If an assistant has worked as a dental assistant for more than one dentist during the required time period, the candidate may attach a letter on offi ce let-terhead from all dentists worked for during the time period. Each letter must be signed and dated by the dentist and include the dentists license number, the month and year the assistant began and ended employment, if the assistant was employed full or part time and that the assistant worked as a dental assistant. This form must be completed by at least one of the candidates current or former employers and included with the application. DANB will accept multiple work experience statements in lieu of letters from former employers.

By signing this form, I further attest that I have personally trained or can verify that the candidate has been trained in the fol-lowing areas. During the tenure of employment, if this candidate has not performed all of these functions in the offi ce, he/she must still possess a basic understanding of them in order to increase his/her likelihood of success on the exam. If the candidate has not been trained in or has not demonstrated basic knowledge of all areas listed below, he/she is not eligible to sit for the exam and should not apply to take this exam until these functions have been performed or knowledge has been demonstrated.

16

Credit Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ CVV __ __ __ Expiration Date __ __/__ __

2015 Radiation Health and Safety (RHS) Exam, Infection Control (ICE) Exam or RHS/ICE Exam

This 2015 application will be accepted through Dec. 31, 2015. After Dec. 31, 2015, download a 2016 application packet from www.danb.org.

I hereby affi rm that my answers to all questions are true and correct, I have met all eligibility requirements, and I will comply with all DANB policies and procedures. I understand that if this exam (or exams on the RHS/ICE application) complete(s) the requirements to earn CDA or COA certifi cation, I attest to holding a current DANB-accepted hands-on CPR, BLS or ACLS card. I further affi rm that I have read and understood the Application Statements contained on page 10, and I intend to be legally bound by them. I understand that the $50 application fee is not refundable under any circumstances.

Signature X____________________________________________ Date X____________________________

Signature and Date Must be signed and dated or the application will be returned as incomplete.

1. It is the responsibility of the candidate to ensure that this application is signed and dated, the background information questions are answered, and all required documentation and fees are included and submitted to DANB. Incomplete applications will be returned with a refund minus the $50 nonrefundable application fee.

2. Mail or fax completed application to DANB. Checks must include the candidates name.

Check the exam you would like to take. q RHS exam q ICE examq RHS/ICE exam (RHS and ICE exams taken together)

Background Information All three questions in this section must be answered or application will be returned as incomplete.Read the questions in their entirety on page 11. Failure to answer all three questions will result in the application being returned as incomplete. If you checked Yes for any question, make sure to include required documentation.

Candidate Information Must be fi lled out completely or application will be returned as incomplete.I am a U.S. citizen. q Yes q No Non-U.S. citizens will be provided a temporary number by DANB in lieu of a Social Security #. I work in a state different than the one in which I reside. q Yes q No If yes, what state:_____ English is the language I speak at home. q Yes q No I work in a dental offi ce. q Yes q No I work in a dental offi ce that uses: q digital radiography q automatic processing q manual processing (check all that apply)

Name (must match your ID exactly)_______________________________________________________________________________

Prior Name (if applicable)____________________________________ Email______________________________________________

Home Address___________________________________________ City________________________ State________Zip_________

Phone Numbers: Offi ce(___)_______________ Home(___)_______________ Cell(___)_______________ Fax(___)_______________

Last First Middle Name or Initial

(Please type or print with a pen.)

Candidates SS#

__ __ __-__ __ -__ __ __ __

RHS exam (3625)ICE exam (3630)

RHS/ICE exam (3616)

q Traditional candidate: q Employed in Maryland: q Active military personnel:

Candidates Name_________________________________________________ Candidates SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Payment Information Must be fi lled out completely or application will be returned as incomplete.

By signing, the cardholder acknowledges intent to register for the aforementioned DANB exam in the amount of the total shown hereon and agrees to perform the obligations set forth in the cardholders agreement with the issuer. Furthermore, the cardholder understands that the signature obtained at the exam administration shall be used to indicate receipt of purchase. A candidate who fails to show up for the exam for which he/she registered and has not canceled the exam as described in this packet is still required to pay for the exam. (See Application Statements for further requirements.)

Cardholders Name___________________________________________ Cardholders Signature X_________________________________________

Cardholders Billing Address_______________________________________________ City________________________________________________

State__________________________ Zip __________________________ Daytime Phone number (______)__________________________________

Mail: DANB 444 N. Michigan Ave., Suite 900 Chicago, IL 60611 OR Fax: 312-642-8507 Questions? 1-800-367-3262 or www.danb.org Do not fax twice or you will be charged twice.

Revised 10/1/12

Employed in MD or NJ ONLYState Approved School ID #

__ __ __ __ (see insert)

q CODA-accredited program (dental assisting/hygiene) See Appendix A for program codes. Graduation year/Anticipated graduation year ________ Program code ________q On-the-job-trained dental assistant Years of experience _____/_____ (years/months)q U.S. D.D.S./D.M.D. or international dental degree q Previous DANB certifi cant: Prior DANB certifi cation number ___ ___ ___ ___ ___ ___q Non-CODA-accredited program (dental assisting/hygiene) See www.danb.org for program codes. Graduation year/Anticipated graduation year ________ Program code ________

Education/Experience Information This information is optional. No documentation required.For our records, please indicate your education/experience.

RHS only: $175 ICE only: $175 RHS/ICE exam fee: $250RHS only: $195 ICE only: $175 RHS/ICE exam fee: $270RHS only: $170 ICE only: $170 RHS/ICE exam fee: $240

RHS (3625) ICE (3630) RHS/ICE (3616)For offi ce use only.

1. Regarding felony convictions within the last fi ve years or sentences currently being served for felony convictions

No Yes

2. Regarding having ever been disciplined by a regulatory board, certifying or examination agency or educational institution

3. Regarding ever being declared mentally incompetent by a court of law

No Yes

No Yes

q Check/Money Order (payable to the Dental Assisting National Board, Inc. or DANB)q Credit Card Authorization (VISA, Mastercard, Discover & American Express accepted): Amount $_____________



Exam Study Help and Reference Materials

CDA Exam BlueprintsPlease visit www.danb.org to download exam blueprints. All exam items are coded to the exam blueprint.

Review the exam blueprint Familiarize yourself with the terminology presented Assess your knowledge regarding all content areas

Reference MaterialsPlease visit www.danb.org to download the exam references suggested by the DANB exam committees. These references can be obtained through sellers, libraries or online.

Certifi ed Dental Assistant (CDA) ExamThe CDA exam consists of 320 multiple-choice items and is made up of three component exams: GC, RHS and ICE. The candidate must meet minimum performance standards on each component exam to earn a CDA certifi cation.

General Chairside Assisting (GC)120 multiple-choice items

1 hours testing timeSub-Content Areas % on examCollection and recording of clinical data 10Chairside dental procedures 45Chairside dental materials (preparation, 9

manipulation, application)Lab materials and procedures 4Patient education and 10

oral health management Prevention and management of emergencies 12Offi ce operations 10

Radiation Health and Safety (RHS)100 multiple-choice items

1 hours testing timeSub-Content Areas % on examExpose and evaluate 26Quality assurance and radiology regulations 21Radiation safety for patients and operators 31Infection control 22

Infection Control* (ICE)100 multiple-choice items

1 hours testing timeSub-Content Areas % on examPatient and dental healthcare 10

worker education Prevent cross-contamination and disease transmission 20Maintain aseptic conditions 10Perform sterilization procedures 15Environmental asepsis 15Occupational safety 30*References 2003 CDC Guidelines for Infection Control in Dental Health-Care Settings and Occupational Safety and Health Administration (OSHA) Standards

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Prepare for DANB Exams


ALABAMA0753 Calhoun Comm. Coll.0754 Faulkner State Community College0346 Fortis College0822 Lawson State Comm. Coll.-Bessemer0864 Trenholm State Technical College0790 Wallace State Community College

ALASKA0501 University of Alaska-Anchorage ARIZONA0503 Phoenix College0743 Pima County Community College0605 Rio Salado College ARKANSAS0255 Arkansas Northeastern College0505 Pulaski Technical College CALIFORNIA0511 Cerritos College0514 Chaffey Community College0515 Citrus College0534 City College of San Francisco0506 College of Alameda0523 College of Marin0838 College of the Redwoods0536 College of San Mateo0745 Contra Costa College0518 Cypress College0516 Diablo Valley College0517 Foothill College0776 Hacienda LaPuente Adult Ed.0257 Heald College-Concord Campus0259 Heald College-Hayward Campus0261 Heald College-Stockton Campus0270 Moreno Valley College0528 Orange Coast College0721 Palomar Community College0529 Pasadena City College0532 Sacramento City College0512 San Diego Mesa College0535 San Jose City College0538 Santa Rosa Junior College COLORADO0804 Front Range Comm. Coll.-Larimer0250 IntelliTec Medical Institute0722 Pickens Technical College0540 Pikes Peak Community College0502 Pueblo Community College CONNECTICUT0543 A. I. Prince Technical High School0885 Lincoln College of New England0875 Tunxis Community College0545 Windham Technical High School

FLORIDA0178 Atlantic Technical Center 0778 Broward Community College 0907 Charlotte Tech. Center0251 College of Central Florida0877 Daytona State College0504 D.G. Erwin Technical Center

FLORIDA (cont.) 0823 Eastern Florida State College4001 Florida State College at Jacksonville0549 Gulf Coast State College (day)0591 Gulf Coast State Coll. (online weekend)0533 Hillsborough Community College0839 Indian River State College0170 Lincoln Technical Institute-Fern Park0550 Lindsey Hopkins Technical Ed. Ctr.0852 Lorenzo Walker Inst. of Technology0551 Manatee Technical Institute0531 Northwest Florida State College0805 Orlando Technical Center0688 Palm Beach State College0555 Pinellas Technical Education Center0915 Robert Morgan Educational Center0554 Santa Fe Community College0530 South Florida State College0609 Tallahassee Community College0723 Traviss Career Center

GEORGIA0895 Albany Technical College0894 Athens Technical College0965 Atlanta Technical College0557 Augusta Technical College0258 Columbus Technical College0262 Georgia Northwestern Tech. College0914 Gwinnett Technical College0901 Lanier Technical College0966 Ogeechee Technical College0908 Savannah Technical College0610 Southern Crescent Technical College0962 Wiregrass Georgia Technical College HAWAII0265 Heald College-Honolulu Campus0785 University of Hawaii Maui College IDAHO0932 Carrington College of Boise 0559 College of Western Idaho- Cosponsor of Boise State University ILLINOIS0561 Elgin Community College0755 Illinois Valley Community College0891 John A. Logan College0562 Kaskaskia College0724 Lewis and Clark Comm. College INDIANA0979 C4 Columbus Area Career Connection/Ivy Tech. State0725 Indiana Univ. School of Dentistry0729 Ind. U. Sch. of Dentistry-distance0794 Indiana Univ. Northwest-Gary0574 Indiana Univ.-Purdue Univ.-Ft. Wayne0647 International Business College0254 Ivy Tech Comm. College-Anderson0572 Ivy Tech Comm. College-Kokomo0795 Ivy Tech Comm. College-LaFayette0986 Ivy Tech Comm. College-South Bend0857 Kaplan College0573 University of Southern Indiana

IOWA0577 Des Moines Area Comm. College0579 Hawkeye Community College0993 Indian Hills Community College0581 Iowa Western Community College0582 Kirkwood Community College0583 Marshalltown Community College0756 Northeast Iowa Comm. College0727 Scott Community College0260 Vatterott College-Des Moines Campus0584 Western Iowa Tech Comm. Coll. KANSAS0585 Flint Hills Technical College0987 Labette Community College0602 Salina Area Tech. School0587 Wichita Area Technical College KENTUCKY0902 Bluegrass Comm. & Tech. Coll.- Leestown Campus0881 West Kentucky Tech. College MAINE0846 University of Maine Augusta/ University College of Bangor MARYLAND0988 Hagerstown Community College MASSACHUSETTS0596 Massasoit Community College0598 McCann Tech. School0601 Middlesex Community College0184 Mount Wachusett Community College0769 Northern Essex Community College0600 Quinsigamond Community College0726 Southeastern Technical Institute0606 Springfi eld Technical Comm. Coll. MICHIGAN0171 Baker College-Auburn Hills0655 Baker College-Port Huron0608 Delta College0612 Grand Rapids Community College0758 Lake Michigan College0611 Mott Community College0780 Northwestern Michigan College0619 Washtenaw Community College0824 Wayne County Comm. College MINNESOTA0620 Central Lakes College0747 Century College0648 Dakota County Technical College0728 Hennepin Technical College0734 Herzing University0622 Hibbing Community College0882 Minneapolis Comm. & Tech. College0621 Minnesota West Comm. & Tech. Coll.0760 Minn. St. Comm & Tech Coll.-Moorhead0759 Northwest Tech. College-Bemidji0626 Rochester Community & Tech. Coll.0748 St. Cloud Technical College0623 South Central Tech. College-Mankato

Appendix A: CODA-Accredited Dental Assisting Programs

Dental assisting educational programs accredited by the Commission on Dental Accreditation (CODA), as of August 2014, are listed below. Can-didates who are students or graduates of any of these programs should mark the number of the program and year of graduation in the spaces provided on the application. For the most up-to-date list of CODA-accredited dental assisting programs, go to www.danb.org. If the candidates CODA-accredited dental assisting program is not listed, please call 1-800-367-3262.


Appendix A: CODA-Accredited Dental Assisting Programs

MISSISSIPPI0627 Hinds Community College0266 Meridian Community College0671 Pearl River Community College MISSOURI0166 Missouri College0854 Nichols Career Center0629 Ozarks Tech. Community College0935 Metropolitan Com. Coll.-Penn Valley0936 St. Louis Comm. College-Forest Park MONTANA0633 Montana State Univ.-Great Falls0816 Salish Kootenai College NEBRASKA0634 Central Community College0172 Kaplan College0637 Metropolitan Community College0636 Mid-Plains Community College0635 Southeast Co

Documents

Certified Dental Assistant