National Dental Assisting Examining Board – International Applicant Submissions (Including USA) NDAEB Dental Assisting Course Work Report – Revised January 2023 - 13 - 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 Written Examination, the NDAEB will collect personal information about me including: my name, photograph, mailing address, 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 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 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 and/or Clinical Practice Evaluation (CPE), my NDAEB Certificate Number, the date of my examination sitting, the date of my taking the CPE and the date of the completion of my Transfer of Credentials (ToC)to the Canadian Dental Assisting Regulatory Authority (CDARA) in the province in which I wrote the exam and/or took the CPE, to any other CDARA requesting information about me and to any other CDARA to which the NDAEB considers, in its sole discretion, that such disclosure is appropriate. I understand that my full name, NDAEB Certificate Number and issue date will be made publicly available on the NDAEB website's national NDAEB Certificate Registry. I understand that the NDAEB may 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 above and in the said NDAEB policy. I hereby give my consent to the NDAEB to contact me by email as necessary to provide me with information regarding the NDAEB exam. Signature:______________________________________________ Date:_____________________ Printed Name: ________________________________________________ Notes made by NDAEB: ________________________________________
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