I understand that for the purpose of assessing my application to register for and participate in the Written Examination and/or Clinical Practice Evaluation (CPE), the NDAEB collects personal information including: my name, photograph (for identification purposes at the examination facility), 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 also 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 may be required to 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, I may be required to provide written confirmation from a religious leader before the NDAEB considers my request. I have read the NDAEB Privacy Policy regarding the collection, use, disclosure and protection of my personal information and I have been provided with contact information and a telephone number should I have questions or concerns. The NDAEB Privacy Policy, which governs the NDAEB’s practices with respect to the collection, use and disclosure of personal information, is readily available at https://ndaeb.ca/privacy-policy/. As indicated in the NDAEB Privacy Policy, I understand that I may request access to my personal information and request that corrections be made. I may also refuse to provide some personal information or request to withdraw my consent; however, some personal information is necessary to fulfill the NDAEB’s mandate. As such, the NDAEB may be unable to provide its services if necessary personal information is not provided. I understand that, as part of the mandate and in the interest of public safety, the NDAEB may disclose personal information, which may include my name, my pass/fail result(s) of the 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 my address is listed, 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 the NDAEB may retain my personal information as long as is necessary to meet the requirements of the NDAEB mandate. I hereby give my consent to the NDAEB to collect, use, disclose and protect my personal information as set out above. I consent (): _______ I do not consent (): _______ I hereby give my consent to the NDAEB to contact me by email as necessary to provide me with information regarding the NDAEB examination and/or Clinical Practice Evaluation (CPE). **NDAEB will NOT accept the Consent for Personal Information Form signed electronically. If the signature, date and/or name are not included on the Consent for personal Information Form, a new completed form will need to be mailed to head office before the application can be reviewed. Signature: _____________________________________________ Date: _________________________ Printed Name: ________________________________________________________ Contact Us: Information Officer (Responsible for privacy compliance) NDAEB Stephen Grundy, CAO/Registrar 204-2283 St. Laurent Blvd. Ottawa, Ontario K1G 5A2 Ph: 613-526-3424 • Fax: 613-526-5560 • E-mail: office@ndaeb.ca Consent for Personal Information Form • 2024 ! Consent for the processing of personal information by the NDAEB for purposes related to the assessment of my application and administration of examinations.
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