Clinical Faculty (Professorial, Clinical, Instructors, Lecturers), Clinical Staff, Clinical Research Personnel

UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRY Office of Patient Services MEMORANDIUM TO: FROM: SUBJECT: Clinical Faculty (Professorial, Clinical, Instructors, Lecturers), Clinical Staff, Clinical Research Personnel Stephen J. Stefanac, DDS, MS Associate Dean, Patient Services Credentials Program at the School of Dentistry In an effort to keep current in our attention to risk management and to maintain accurate and complete records for compliance purposes all Clinical Faculty, Clinical Staff, and Clinical Research Personnel at the School of Dentistry are required to complete the attached credentialing forms. Read over and fill out the attached forms carefully, completing each section accordingly. When you have completed all sections of each form remember to include applicable copies of your current: Cardiopulmonary Resuscitation Certification (CPR card) Federal DEA (Controlled Substance) License Michigan DEA (Controlled Substance) License Michigan Dental Assistant License Michigan Dental Hygienist License Michigan Dental License Michigan Specialty Certificate Verification of Hepatitis B immunization Verification of Tuberculin Skin Test Also required for our records, will be your current National Provider Identifier (NPI) number. When completed and approved, these documents will also be used for those faculty who wish to practice in the Dental Faculty Associates clinic. All credentials information is held in the strictest confidence and will be monitored on a regular basis. When your applicable license(s) approach their expiration date you will be notified to send a copy of your renewed license to your department Administrative Associate. Complete the attached forms, attach appropriate document copies and return to your department s Administrative Associate.

The University of Michigan School of Dentistry Faculty/Auxiliary Staff Credentials Form PREAMBLE The faculty and auxiliary staff of the School of Dentistry are responsible for the quality of care rendered to patients. Standard of care is a reflection of professional competence and goals established to obtain optimal dental health. Several criteria are accepted as evidence of competence, including those required by State laws and those established by the School of Dentistry. The criteria include education, licensure, experience, certification, service, appointments and health of the applicant. All dentists and associated health professionals who are actively engaged in the treatment of, or who are responsible for supervising the treatment of patients in teaching clinics, in research or various kinds of service clinics, are required to furnish the School of Dentistry with the credentials information requested. Competence must correspond to the health service provided. Name in full: Last First Middle Department: Office No. Phone No. Education: Dental School Degree Date of graduation Graduate Dental Education: School Degree Field Date Certificate Date School Degree Field Date Certificate Date Teaching Appointment: Date Rank/Title Teaching Appointment: Date Rank/Title Research Appointment: Date Rank/Title Research Appointment: Date Rank/Title Private Practice Experience: Address City/State Inclusive Dates

Hospital Appointment: Hospital Address Inclusive Dates Military Dentist Experience: Inclusive Dates: Military Dentist Experience: Inclusive Dates: Membership in Dental Societies: Certification: American Board: Date Licensures: (Copies to be attached) Michigan Dentist Lisc. # Issue Date Exp. Date Michigan Specialty Lisc. # Issue Date Exp. Date MI Controlled Substance Lisc. # Issue Date Exp. Date National Practitioner Identifier (NPI) Federal DEA License # Expiration Date Michigan Dental Hygienist License # Issue Date Exp. Date Michigan Dental Assistant License # Issue Date Exp. Date Additional Information: Basic Life Support (BLS) Certification: Exp. Date Advanced Cardiac Life Support (ACLS) Certification: Exp. Date Hepatitis B Date of Inoculation Tuberculin Skin Test Date

If the answer to any of the following questions is Yes, please give full details on a separate sheet of paper. Has your license to practice dentistry in any jurisdiction or your DEA license ever been limited, suspended or revoked? Yes No Have your privileges at any practice or teaching site ever been suspended, diminished, revoked, or not renewed? Yes No Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any organization of dentistry? Yes No Has a malpractice judgment been made against you or settled out of court, or is a malpractice claim pending? Yes No Have you been the subject of any completed or ongoing peer review investigations? Yes No Do you have any significant physical, mental, or medical problems which could interfere with your ability to perform duties for which you are appointed? Yes No Do you have any contagious or communicable disease which will endanger others? Yes No Please check the appropriate box for the statement which applies to you: D.D.S. and Dental Hygiene Clinical Faculty: Should there be reasonable cause to believe that I am unable to discharge my clinical, administrative and/or educational responsibilities appropriately due to an alcohol or drug problem, I understand that I may be required to undergo an appropriate alcohol and/or drug screen to determine whether such a problem is present. I further understand that I may be temporarily suspended from my responsibilities pending completion of such an evaluation. (Section III. B. 1., U of M School of Dentistry Faculty, Staff, and Student policy on Alcohol and Other Drugs). Dental Auxiliary: Should there be reasonable cause to believe that I am unable to discharge my clinical responsibilities appropriately due to an alcohol or drug problem, I understand that I may be required to undergo an appropriate alcohol and/or drug screen to determine whether such a problem is present. I further understand that I may be temporarily suspended from my responsibilities pending completion of such an evaluation. (Section III. B. 2., U of M School of Dentistry Faculty, Staff, and Student policy on Alcohol and Other Drugs). I authorize the Dean of the School of Dentistry, or his designate, to consult with references that I provide in support of my credentials or with others who may have information bearing on my competence, character or ethical qualifications. I fully understand that any misstatements in, or purposeful omissions from this application may be cause for denial of appointment and/or be cause for referral to the Credentials Committee for appropriate action. I agree to provide for continuous quality care and supervision of patients, and to report to the Office of Patient Services any change in my health status that would affect my ability to practice dentistry. I agree that a loss of credentials will affect my ability to treat patients and may lead to my dismissal. Signature Date THE OFFICE OF PATIENT SERVICES MUST BE INFORMED OF ANY CHANGE IN THE INFORMATION SUBMITTED OR IN THE STATUS OF THE APPLICANT WITHIN 30 DAYS.

REQUEST FOR APPROVAL OF PRIVILEGES Privileges are granted for the category of the provider and the general and specialized procedures. Indicate the category of provider requested and the services you are requesting to perform as a faculty or staff member of the School of Dentistry. Requested Approved Category #1: Dentist unrestricted privileges: activity or procedure may be conducted under own recognizance (full dental licensure, State of Michigan). Category #2: Dentist restricted privileges; activity or procedure may be conducted under supervision (limited dental licensure, State of Michigan). Category #3: Dental Hygienist: (full license) Category #4: Dental Hygienist: (limited license) Category #5: Dental Assistant Category #6: Dental Assistant: (registered dental assistant) Category #7: Medical Technologist: (certification) Category #8: Registered Nurse GENERAL PRIVILEGES: Within the scope of licensure in the State of Michigan

SPECIAL PRIVILEGES: Requested Approved Provide consultative services as a specialist in within and outside the University. Hospital privileges Hospital admitting privileges I.V. Sedation General anesthesia Pre and post surgery care of the hospitalized patient Administration of I.V. medications Electromyographic evaluation of masticatory and associated muscles. Sialography, including diagnosis Arthography, including diagnosis Arthoscopy, including diagnosis Implants surgery Implant rehabilitation Hypnosis Acupuncture T.E.N.S. (Transcutaneous Electric Nerve Stimulation) Electronic jaw movement tracking Other procedures: Signature Applicant Signature Department Chair Credentials Committee Approval Signature Patient Care Dean Date Date Disapproval Date

SERVICE AND RANK TO BE COMPLETED BY UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRY DEPARTMENT CHAIRMAN I hereby recommend for membership in Applicant the Dental Faculty Associates clinic of The University of Michigan within the Department of. Academic Rank Effective Date MEMBERSHIP CATEGORY REQUESTED Attending Faculty with Clinical Privileges ENDORSEMENT AND PRIVILEGES I personally attest to the accuracy of the information contained in this application and the applicant s current clinical competence. RESTRICTION I further attest that the applicant is duly qualified by training and/or experience to perform such procedures and services provided in the specified Department for patient care except as indicated below. Signature Department Chair Date DFA MEMBERSHIP APPROVALS CREDENTIALS COMMITTEE Approved Disapprove Comments: Date Signed Credentials Committee DEAN, SCHOOL OF DENTISTRY Date Approved Disapprove

PROCEDURAL GUIDELINES FOR CLINICAL PRIVILEGES A. Clinical privileges for faculty of the School of Dentistry will be determined by the Credentials Committee in accordance with documented education, training, experience, current competency, peer recognition, and licensure. Requests for clinical privileges are initiated by the chair of the department in which the privileges will be exercised. B. Every dentist and associated health professional teaching, practicing or conducting research at the School of Dentistry, and/or any affiliated institution shall, in connection with such practice, be entitled to exercise only those clinical privileges granted to him/her. Specific limitations on an individual s privileges to treat patients or to direct the course of treatment for which the patients were admitted shall be stated in the clinical privileges. C. Before being appointed to a position in the School of Dentistry where treatment of patients or supervision of treatment is a requirement of that position, the qualifications of the prospective appointee for appropriate licensure and clinical privileges must be reviewed by the Credentials Committee. D. Every initial application for faculty appointment must contain a written request for the specific clinical privileges desired by the applicant. The evaluation of such requests shall be based upon the applicant s education, training, experience, demonstrated competence, references, peer recommendations, and other relevant information including an appraisal by the clinical department in which such privileges are sought. The applicant shall have the burden of establishing his/her qualifications and competency in the clinical privileges he/she requests. E. Clinical privileges will be granted by the Credentials Committee for a period of one year upon initial appointment and every two years thereafter. Renewal of privileges will be based on annual documented proficiency ratings, and other reasonable indicators of continuing qualifications, including necessary renewals of licensures. F. The Credentials Committee will consist of the six faculty members of the Clinic Operations Committee. Specialty interest shall be represented on the credential committee. Members will serve for 3 year terms. The Associate Dean for Patient Services will serve as chair of the Credentials Committee. G. Privileges granted by any Human Subjects Committee in the University of Michigan to conduct research on human subjects does not abridge the requirement to satisfy the requirements of the Credentials Committee. H. Every dentist and associated health professional treating, directing student treatment, or conducting research on patients must be certified in CPR.

I. Criteria for the delineation of clinical privileges will be prepared in the following categories by each clinical discipline: 1. General proficiencies in caring for patients acquired through primary professional education. 2. More specialized proficiencies provided through specialty training and/or certification. 3. Specific techniques often utilizing newer modalities or equipment in patient care. J. A member of the faculty or staff who does not possess the privilege to perform a particular procedure or treatment cannot supervise another member of the faculty, staff or student in the performance of that treatment or procedure. K. Each member of the clinical faculty and staff must have a completed and approved Request for Clinical Privileges, listing those clinical privileges which have been granted, on file in the office of the Dean. L. A copy of the faculty or staff member s approved clinical privileges shall be supplied to him/her as written notification that clinical privileges have been granted. M. Denial of clinical privileges, initially or at renewal, is determined solely by the Credentials Committee. The director of a discipline or chair of a department may request re-evaluation of an individual s credentials and make recommendations to the Credentials Committee. Denial of renewal of clinical privileges is not grounds for loss of tenure. N. An annual verification and attestation statement is required although no in depth review is conducted. O. A written communication to the Dean from a claimant expressing dissatisfaction or disagreement with the decision of the Credentials Committee concerning his/her request for clinical privileges, will constitute the beginning of the appeal process. This written communication requesting re-evaluation must be received by the Dean s office not later than ten working days after the mailing date (certified mail) of the notice of the decision. Upon receipt of the claimant s written communication for re-evaluation of his/her request for clinical privileges, the Dean may designate the Executive Committee to preside over the appeal proceedings. The Executive Committee will notify the claimant of the date and time of his appeal hearing. The Executive Committee and/or the claimant may call upon a consultant(s) from outside the School of Dentistry, in the requested clinical privilege(s) area, to lend their expert opinion on the claimant s qualifications to perform the requested clinical procedures. The Committee will make an appropriate recommendation to the Dean who is the deciding official.

Privileges Policies The policies governing the granting of privileges to the dental faculty shall be established by the Credentials Committee with the approval of the Dean and the Executive Committee. Specific departmental or specialty privileges shall be included in the appropriate section. Credentials Committee The Credentials Committee is charged with establishment and maintenance of the educational, experiential and licensure requirements necessary for optimal care of patients. All dentists, dental hygienists and auxiliary personal who are engaged in some aspect of the diagnosis and/or treatment of patients must satisfy the requirements established by the Credentials Committee. Credentials refers to evidence of having obtained the necessary education, experience, and licenses to provide the care for which privileges are being requested. The term also refers to maintaining the necessary licensure to provide such services and any additional education and/or experience necessary to keep abreast of changes in patient care. The Credentials Committee shall make decisions on whether or not credentials do provide the evidence to meet the established requirements for the privileges requested. The committee will act on matters of professional competency that are directly related to credentials. Except in cases of fraudulent credentials the committee shall make no recommendations for specific action. However, the Dean and Executive Committee may, when in the best interests of patient care, direct that privileges be withdrawn until the question of competency has been established. The chair of the Credentials Committee (Associate Dean for Patient Services) shall provide the Dean and Executive Committee with those instances where evidence of credentials is not adequate to grant the clinic privileges requested. Denial or withdrawal of privileges must come from the Dean of the School of Dentistry.

Hepatitis B Virus Vaccine Information Sheet and Consent Form UNIVERSITY OF MICHIGAN School of Dentistry Name Faculty Staff Date The following information describes the risk of acquiring hepatitis B and the side effects of the vaccine. Hepatitis B: Hepatitis B virus causes a systemic infection with major effect on the liver. Symptoms may include nausea, loss of appetite, fatigue and weakness. Some persons may develop chronic hepatitis, liver cancer or die of the acute illness. Transmission is by exposure to blood or bloodcontaminated body fluids of an infected person through breaks in the skin or mucous membrane surfaces of a non-immune person. The incubation period ranges from 40-180 days. Immunization: Hepatitis B vaccine is a non-infectious, sub-unit viral vaccine produced by recombinant DNA techniques. One cannot develop hepatitis, AIDS or any other viral illness from receiving the vaccine. After a typical series of three (3) doses of the vaccine over six months, an average of over 90% of healthy adults develop antibodies, which protect against development of hepatitis B. The duration of protection is at least three years. Hepatitis B vaccine is recommended for all persons who are at increased risk of infection with hepatitis B virus, including some health care workers. The vaccine is neither helpful nor harmful in hepatitis B virus carriers or persons with existing antibodies to hepatitis B. Special Considerations: Because it is unnecessary, the vaccine is not recommended for persons with immunity to hepatitis B. 1. Do you believe you are immune to hepatitis B either through natural infection or previous vaccination? (If yes, documentation must be submitted) yes no Explain: Procedure: After signing this consent, if you have not already begun receiving the hepatitis B virus vaccine, you should make arrangements to do so. The immunization is received in three doses (dose 1, now, dose 2, one month from now and dose 3, six months from now). The immunization injections are done at minimal cost to you. Once the immunization series is completed, you may request a blood test for antibody to hepatitis B virus. If the antibody test indicates you are not yet immune, additional doses may be recommended and provided at cost to you. Some people do not seroconvert. It is in your best interest to get your titer checked for presence of antibody. University students can be tested for antibody determination at University Health Service during a period of 3-12 months after completing the third inoculation. A positive hepatitis B titer is usually good for 7-12 years.

Consent: I have read the above statements about hepatitis B virus vaccine and have received satisfactory answers to all my questions. I understand that in my training at the School of Dentistry I may be at increased risk of contracting hepatitis B virus, and that immunization has been recommended to prevent my becoming infected or ill. I consent to receive injections of hepatitis B virus vaccine and to have blood drawn following the series. Signature: Witness: I consent to have blood drawn for hepatitis B antibody level determination. OR Signature: Witness: I refuse the blood tests and immunizations for hepatitis B virus that have been offered to me.* OR Signature: Witness: *Failure to be tested or immunized will not jeopardize your student status. It has been explained to me why I do not need to be vaccinated at this time and I agree to that. OR Signature: Witness: Return Completed Form To: Office of Patient Services University of Michigan School of Dentistry 1011 N. University, Room 1301 Ann Arbor, Michigan 48109-1078

UNIVERISTY OF MICHIGAN SCHOOL OF DENTISTRY MANTOUX SKIN TEST INFORMATION SHEET AND CONSENT FORM It shall be the policy of the University Of Michigan School Of Dentistry to maintain a Tuberculosis Screening Program to protect faculty, staff and students. TB skin testing is available at no charge to employees and at a minimal charge to students through University Health Services. The following information describes the skin test procedure. TB Screening: Includes skin testing to detect TB infection. When a skin test is applied, screening is considered complete after the test has been checked 48-72 hours after application and subsequent evaluation completed if indicated, as specified by University Health Services (UHS) protocols. When a chest x-ray has been ordered by UHS, screening is considered complete after the x-ray has been taken and subsequent appointments kept as specified in protocols. Reactive Skin Test: Response of ten (10) or more millimeters of induration 48 hours following a Mantoux intradermal injection of 5TU of Tuberculin Purified Protein Derivative. Procedure: After signing the consent below, you will be scheduled to receive the skin test. The skin test must be read by University Health Services within 48-72 hours. It is your responsibility to return to UHS in this time frame for interpretation. Consent: I have read the above statements about the Mantoux skin test and have received satisfactory answers to all my questions. I consent to receive the Mantoux skin test. Signature Date Witness Date

UNIVERSITY OF MICHIGAN SCHOOL OF DENTISTRY AUTHORIZATION FOR UNIVERSITY HEALTH SERVICE INOCULATIONS This is to certify that is an employee at the School of Dentistry and is authorized to receive the following inoculation(s): TB Skin Test (Mantoux) TB Skin Test NOT administered on Thursdays. HBV Vaccination Other (Please Specify) University Health Service bills all inoculations and other specified services to the School of Dentistry Office of Patient Services account. Authorization for this employee to receive the indicated services has been approved by: Department Name: Supervisor Name: Contact Phone No. Employee Supervisor: A copy of this form must be forwarded to Gary Sweier, room 1303, Office of Patient Services, with the appropriate account number to re-charge services to. UHS Allergy and Immunization Clinic 764-8304 Hours of Operation TB skin testing is available Monday, Tuesday, Wednesday and Friday (no Thursday testing), TB skin testing after 1:00 p.m., may possibly have a waiting period from 1 to 1.5 hours. Please note Health Services is closed between noon 1 p.m. everyday. Fall/Winter September to April Monday 8:00-5:00p.m. Tuesday 8:00-5:00.m. Wednesday 8:30-5:00p.m. Thursday 9:00-5:00p.m. Friday 8:00-4:30p.m. Spring/Summer May to August Monday 8:30-4:30p.m. Tuesday 8:30-4:30p.m. Wednesday 8:30-4:30p.m. Thursday 9:00-4:30p.m. Friday 8:30-4:30p.m. This Form Must Accompany the Employee To University Health Services.