Out Of State Radiation Safety Certification - Dental Board Of California
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1BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G. BROWN JR.
Dental Board of California
2005 Evergreen Street, Suite 1550, Sacramento, California 95815
P (916) 263-2300 | F (916) 263-2140 |
OUT OF STATE
For Office Use Only:
RADIATION SAFETY CERTIFICATION
Cashiering No.: __________________
Fee: $50.00
Fee Paid: $ ___________
FEE NON-REFUNDABLE
Completed by: ___________________
Make check or money order payable to: Dental Board of California
Allow 30 days for processing
Date Mailed: ____________________
•
You complete the top portion of this form.
•
The school must complete the bottom portion of this form and return to you to submit to this Board with required fee.
Last:
First:
Middle
Phone No.:
Social Security Number:
Date of Birth:
Your Address:
City:
State:
Zip Code:
TO BE COMPLETED ONLY BY PROGRAMS ACCREDITED BY THE
COMMISSION ON DENTAL ACCREDITATION (CODA)
Graduation Date:
Month:
Day:
Year:
School Name:
Phone No.:
Address:
City:
State:
Zip Code:
I hereby certify under penalty of perjury under the laws of the State of California that the applicant above successfully graduated from a
CODA accredited dental assisting program.
WHICH INCLUDED:
I.
Didactic instruction and demonstration. Sufficient classroom instruction was provided in a least the following subjects:
A.
Radiation physics and biology
B. Radiation protection and safety
C. Intraoral techniques
D. Film exposure and processing
E. Film mounting and viewing
F. Evaluation of radiographs for diagnostic quality
G. Supplemental techniques
II.
Laboratory instruction. Sufficient hours of laboratory instruction were provided to ensure that the applicant listed above successfully
completed at least:
A.
Two full-mouth periapical surveys on a manikin, consisting of at least 18 films, 4 of which must have been bitewings.
B.
Two additional bitewing surveys on a manikin, consisting of at least 4 films each.
C.
All radiographic surveys exposed by the applicant were evaluated for acceptable diagnostic quality.
III.
Clinical Experience. Clinical experience sufficient to reach clinical competence included in the following:
A.
A minimum of 4 full-mouth periapical surveys on human subjects, consisting of at least 18 films, 4 of which must have been
bitewings, exposed for diagnostic purposes only.
B.
Developing, processing and mounting of all exposed radiographs.
All radiographic surveys exposed by the applicant were evaluated for acceptable diagnostic quality. All clinical instruction was performed
under the general supervision of a dentist in accordance with the provisions of Health and Safety Code, Sections 25661, 25671.1, and
25672.
Course Instructor or Administrator’s signature
Stamp or Seal
of college
Course Instructor or Administrator’s name print
Institution
or Program
College Address
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