Examination Information for Candidates for the Hawai i Dental Examination

Transcription

1 Examination Information for Candidates for the Hawai i Dental Examination Candidate Orientation is scheduled for 5:00 PM (1700) on Friday, July 22nd, 2016 at the Hawai i Prince Hotel conference room. The hotel is located at 100 Holomoana St., Honolulu, HI. This is a mandatory orientation. Immediately preceding this mandatory candidate orientation there will be a candidate check-in. The attached Candidate Disclaimer Form must be complete and submitted at this time. In addition, the attached Patient Disclaimer Form(s), one for each patient to be treated, may be submitted at this time or turned in Sunday morning before exam start during operatory set up. The examination is scheduled for July 23 (Endo/Pros Exams) and July 24 (Perio/Rest Exams), 2016 and takes place at the Joint Base Pearl Harbor, Hickam, Branch Health Clinic Makalapa, just inside the Makalapa Gate. All individuals (candidates, assistants, patients and any others) entering the Joint Base Pearl Harbor, Hickam will be required to present a valid driver s license with photo/picture or other form of official, current and valid identification with photo/picture on request and matched to the list provided by CDCA. All individuals participating in this examination must enter the base only through the Makalapa Gate. All drivers will be asked to provide a valid driver s license with photo/picture, automobile registration, safety inspection, and proof of insurance for the car they are driving to enter the base. Rental car drivers will need to show a rental agreement contract. Please allow extra time for entry as security measures may include personnel and vehicle searches. Please be aware that absolute daily access is based upon current force protection conditions. All individuals entering the base must be listed on the personnel access list provided to the Joint Base Pearl Harbor, Hickam Pass and ID office by the CDCA unless they hold their own military credentials. Any additional information required from Joint Base for access will be communicated with all candidates to allow for submission of required information to request base access for those not holding their own military credentials. In order to permit entry onto Joint Base Pearl Harbor, Hickam, candidates must provide the following information directly to CDCA s ADEX Hawai i Examination Coordinator, Kathy Kelly (kathyjkelly@aol.com), by June 30th: 1. First Name, Middle Initial, and Last Name of your patients (if you have more than one patient for a procedure, specify who is the primary and who is the backup patient). See candidate manual for patient eligibility and submissions. Only one patient may be submitted for the Periodontal Examination. 2. First Name, Middle Initial, and Last Name of all other persons (dental assistants, drivers, interpreters, CANDIDATES, etc.) who will be entering Joint Base Pearl Harbor, Hickam. 3. Notification if you will need a unit/chair that is set up for a left handed dentist. 4. The last four digits of the Social Security number of each person access is being requested for along with their date of birth (Month/Day/Year 00/00/0000) All persons, w h o d o n o t o t h e r w i s e h a v e m i l i t a r y a c c e s s t o t h e b a s e, m u s t p r o v i d e t h i s i n f o r m a t i o n t h r o u g h t h e c a n d i d a t e t o t h e A D E X H a w a i i E x a m i n a t i o n C o o r d i n a t o r no later than June 30th, No changes/additions/amendments will be permitted after this date. Any patient changes after this date will not be allowed or accommodated due to base access direction. Any additional information required from Joint Base for access will be communicated with all candidates to allow for submission of required information. This information must be submitted in Excel table format with the data noted in a separate field. You must specify which date(s) each person will need access requested.

2 This required information must be provided by to CDCA cannot guarantee access to the base if you do not submit the names (as noted, first, middle initial and last name) last four digits of the social security number, and date of birth (all in the manner noted) to the ADEX Hawai i Examination Coordinator by the deadline of June 30 th for base review and approval. PLEASE NOTE THIS SPECIFIC INFORMATION REQUIRED IS TO BE SENT TO THE ADEX HAWAI I EXAMINATION COORDINATOR Kathy Kelly and not to Department of the Navy or US government personnel. No changes may be made after this date. Access to the base is the sole purview of the US Government, Department of the Navy. Candidates will be notified if any access permission is denied for themselves or any person they have requested such access for including patients. Be sure that you, your patient(s), assistant, and any other companion(s) possess the appropriate valid photo identification from a state or US governmental entity and will be able to present this valid photo identification at the examination as stated above. Only those individuals necessary for the exam will be included on the base access request list. Without proper identification, you and your patient(s), and others will not be allowed to participate in the examination even if you were possibly granted access to the base. No exceptions. ABOUT THE TESTING SITE: Since the examination is taking place at a federal facility and not a dental school, only the clinic space is made available, no equipment, supplies or disposables will be provided by the clinic other than as noted on this form. As the testing agency must provide the infection control supplies as well as compensation for military personnel who are available for any needed equipment maintenance, radiography, and support, there is a facility use fee of $150. This facility use fee will be collected as part of the online registration process. Please see the attached list of ONLY those infection control and supply items that will be available at this site. Any amendments to this supply list will be sent to you via to the address you provide CDCA. If you require any other or different supplies, materials, or equipment, you MUST bring those items with you. Limitations on innovative or new technology or prohibited items are identified in the candidate manual. All patients must be provided by the candidate and meet eligibility requirements as noted in the candidate manual. Neither the testing agency nor Branch Health Clinic Makalapa will provide patients for this examination. Please do not bring family members or friends to observe or wait for you during this examination. Only those assistants, interpreters, drivers, and patients will be allowed in the clinic area for their appropriate participation in the examination. Candidates are responsible for providing the following materials and equipment: 1. High-speed turbine handpiece and low-speed handpiece. The handpieces should be able to connect to an Adec standard 4/5-hole coupling, if not, the candidate will need to provide an adaptor to make this connection. The delivery system is over the patient. There is no fiber optic capability. 2. Supplies that will be provided include: See list. A model trimmer, amalgamator and vibrator will be available at the exam site. A sharps container is also available in each operatory. 3. Candidates must bring their own sterilized instruments needed for the planned procedures, plus extra instruments in case of additional needs. Candidates shall not use any of the instruments or supplies belonging to the clinic and shall not tamper with its cabinets, drawers or shelves. Proper storage of used instruments and equipment must be done in accordance with Infection Control Standards. On site sterilization will not be available at this location for candidates.

3 4. Candidates must provide their own light curing equipment, materials, or other instrumentation in their armamentarium. 5. The testing agency will provide only the chair mount, rod, assembly, manikin head, facial shroud, typodont, and teeth used for the Prosthodontics and Endodontics examinations. 6. If the candidate encounters problems with the equipment, a Repair Technician may be summoned by contacting a Clinic Floor Examiner. 7. The Branch Health Clinic Makalapa or the testing agency will not be responsible for any equipment lost, misplaced or left at the clinic. Candidates shall be responsible for any damage to equipment or facilities at the clinic. CANDIDATE CONDUCT: In addition to conduct outlined in the candidate guide, the following are site specific conduct requirements. Candidates shall park only in front of the Branch Health Clinic Makalapa. Friends or relatives are not permitted to wait in the clinic or contact the candidates once the examination has begun. Candidates must clean the operatory (clean evacuation traps, bag and remove trash, disinfect counters and equipment, etc.) and request an inspection of the operatory by a CFE before departing the clinic. The CFE will initial the candidate badge only after proper operatory clean-up has occurred.

4 BOARD OF DENTAL EXAMINERS State of Hawai i PATIENT DISCLAIMER FORM Release, Waiver and Authorization for Release of Confidential Information Release and Waiver of Claims for Damages Read this carefully. You are surrendering your rights. Please print legibly. I, (Patient), in consideration of the free dental work to be performed for and upon me and my desire to assist candidates for the dental licensure examination ( Exam ), do hereby (1) allow candidates for said Exam to perform dental screening and/or dental and dental related procedures and (2) specifically release the state of Hawai i, the State of Hawai i Board of Dental Examiners, the Commission on Dental Competency Assessments and other entities which develop or administer the Exam, and the NAVHLTHCLINIC Hawaii (Branch Health Clinic Makalapa), and all their employees, agents, volunteers, or monitors of said entities, from any claims, damages, actions or causes of action which the undersigned now has or may have, whether or not now known or anticipated, arising out of or to arise out of, or connected with directly or indirectly the screening of patients, and the dental and related procedures to be performed upon me during the clinical examination at Dental Clinic, NAVHLTHCLINIC Hawaii, Pearl Harbor (the Branch Health Clinic Makalapa). I understand that although the procedures will be performed in spaces under the control of the U. S. Navy, no agency or department of the U. S. Government is involved in any manner in the examination or procedures. No procedures will be performed and no services will be provided by any military or civilian employee of the U. S. Government acting in any official capacity. The U. S. Government, the Department of the Navy (DoN), and the NAVHLTHCLINIC Hawaii (Branch Health Clinic Makalapa) do not warrant the procedures or services performed. I specifically release the U. S. Government, the Department of the Navy, Joint Base Pearl Harbor Hickam, and its employees, military and civilian, from any and all claims, actions, causes of action, demands, rights, damages, costs, loss of service, expenses, and compensation whatsoever. I am aware that the candidates who will perform dental work for and upon me are not presently licensed to practice dentistry in the State of Hawai i and that, therefore, the Board of Dental Examiners has not yet made a determination as to whether the candidates possesses the requisite education, training, competence, and skill of a duly licensed dentist in the State of Hawai i. I agree that no representation nor warranties have been made by the State of Hawai i, the State of Hawai i Board of Dental Examiners, the Commission on Dental Competency Assessments, and the entities which develop or administer the Exam, or the NAVHLTHCLINIC Hawaii (Branch Health Clinic Makalapa), or their duly authorized employees, agents volunteers, or monitors, regarding the character, competency or professional skill possessed by the candidates to perform any or all of the dental operations or procedures to which I am voluntarily submitting.

5 With full knowledge and understanding of the above and the consequent risks of accident, injuries or damage, I hereby release the State of Hawai i, the State of Hawai i Board of Dental Examiners, the Commission on Dental Competency Assessments, the entities which develop or administer the Exam, the NAVHLTHCLINIC Hawaii (Branch Health Clinic Makalapa) and their employees, agents, volunteers, and monitors from the responsibility or liability for accidents, injuries, or damages I may suffer as a result of my participation in said screening and/or clinical examination. Furthermore, I authorize (Candidate) to release any and all of my records, reports, information, including dental radiographs, and any other information that he/she may possess to the State of Hawai I, the State of Hawai i Board of Dental Examiners, and the Commission on Dental Competency Assessments. I further authorize the State of Hawai i and State of Hawai i Board of Dental Examiners to release, if necessary, such information to any and all appropriate entities including, but not limited to, the entities which develop or administer the Exam. The nature and effect of the procedure(s) to be performed and the risks involved have been explained to me. I understand that additional treatment related to services rendered during this examination may be required. DATED at Honolulu, Hawai i,, 20 _. Patient s Signature Witness s Signature Patient s Address Witness s Address Note: The witness may be anyone other than the candidate. The patient waiver form (one for each patient to be treated) may be submitted at candidate check-in and orientation otherwise turned in when the candidate initially presents each patient for a start check during the examination along with the other required paperwork.

6 BOARD OF DENTAL EXAMINERS State of Hawai i CANDIDATE DISCLAIMER FORM Release and Indemnity Agreement Read this carefully. You are surrendering your rights and assuming obligations. Please print legibly. I, (Candidate), in consideration of being provided a location in which to be examined by the State of Hawai i Board of Dental Examiners, through its contracted developing and administering entities, do fully and forever release and discharge the U. S. Government, the U. S. Navy, the Branch Health Clinic Makalapa, the State of Hawai i, the State of Hawai i Board of Dental Examiners, the Commission on Dental Competency Assessments, the entities which develop or administer the examination, and its employees, agents, volunteers, and monitors, military or civilian, from any and all claims in any way arising from any and all injuries, losses, and damages to person and property sustained or received while at Branch Health Clinic Makalapa to take said examination. In further considerations of the provision of a location in which to be examined, I hereby agree to hold harmless and indemnify the U. S. Government, the U. S. Navy, the Branch Health Clinic Makalapa, the State of Hawai i, the State of Hawai i Board of Dental Examiners, the Commission on Dental Competency Assessments, the entities which develop or administer the examination, and its employees, agents, volunteers, and monitors, military or civilian, of and from any and all expense arising because of any claim which may hereafter be presented by anyone for loss and damage or personal injury as a result of my participation in said examination. I declare that I fully understand the terms of this release and indemnity agreement. DATED at Honolulu, Hawai i,, 20 _. Candidate s Signature Witness s Signature Candidate s Address Witness s Address Note: The candidate disclaimer form must be submitted at candidate check-in and Orientation.

7 SUPPLIES PROVIDED BY TESTING AGENCY :