Dental Assisting Course Work Report - Canada

National Dental Assisting Examining Board – Graduate of a Canadian Program (Other than Dental Assisting) NDAEB Dental Assisting Course Work Report – Revised September 2021 - 12 - We require your informed consent before registering you for the NDAEB Exam or Clinical Practice Evaluation. Please read the following statements and sign below. Consent for Personal Information I understand that to register for the NDAEB written exam or Clinical Practice Evaluation, the NDAEB will collect personal information about me including: my name, photograph, mailing address, my credit card information (if paying by Visa or Master Card), educational transcripts/diplomas or letter(s) from my school confirming my enrollment in or graduation from an eligible dental assisting educational program. I understand that if I received my dental assisting (or allied) education outside Canada, the required documents will include, but may not be limited to, report(s) from third parties such as translators and international credentials evaluation agencies confirming my academic records. I understand that if I request special exam accommodations for medical or other reasons, I must provide the NDAEB with reports or other documents from third parties such as, educational counselors, psychologists or physicians to support my request. I understand that if I request a special exam sitting date for religious reasons, the NDAEB will require me to provide written confirmation from a religious leader before considering my request. I understand that the NDAEB may verify the authenticity of any documents submitted in support of my application with the originating organization. I have read the NDAEB policy regarding the collection, use, disclosure and protection of my personal information and I have been provided with contact information and telephone number should I have questions or concerns. I understand that should I request my written examination paper after the exam, I will receive a copy of my personal answer sheet which does not include NDAEB test items (questions). I understand that if my examination answer sheet/evaluation form is lost or goes missing before it can be scored by the NDAEB, no result will be awarded. I will be required to re-write the examination, or be re-evaluated, at the next scheduled sitting, at no charge. I understand that, in the interest of public safety, the NDAEB may release any of my name, result(s) of my NDAEB written examination or Clinical Practice Evaluation (CPE), my NDAEB Certificate Number, the date of my exam sitting, the date of my taking the CPE and the date of completion of my Transfer of Credentials (ToC) to the Dental Assisting Regulatory Authority (DARA) in the province in which I wrote the exam/ and or took the CPE, to any other DARA requesting information about me and to any other DARA to which the NDAEB considers, in its sole discretion, that such disclosure is appropriate. I understand that the NDAEB will retain my personal information indefinitely. I understand that should the NDAEB come into possession of any personal information about me in addition to the information referred to above, such information shall not be disclosed without my written consent. I hereby give my consent to the NDAEB to collect, use, disclose and protect my personal information as set out in NDAEB policy. By signing, I hereby certify that the information and documentation given and made part of this application are true and correct in every aspect. Signature: ____________________________________________________ Date: ____________________ Printed Name: ________________________________________________ Notes made by NDAEB: ________________________________________ 204 – 2283 St. Laurent Blvd. Ottawa, ON K1G 5A2 Tel: (613) 526-3424 Fax: (613) 526-5560 Email: [email protected]