National Dental Assisting Examining Board NDAEB Dental Assisting Course Work Report – Revised October 2024 - 1 - DENTAL ASSISTING COURSE WORK REPORT INSTRUCTIONS • Please TYPE OR PRINT your responses. The report must be legible. Altered formats will not be accepted. • Please confirm that all required signatures and dates on the declaration page and personal consent form have been entered. • In the tables below, check () the topic areas covered by your course work in dental assisting (or other formal dental training) and list the title of your courses. • Note that all topic areas that you report being covered by your program must be supported by official documentation from a recognized academic institution and verified by ICES, IQAS or WES in their report. • By completing this document, you are attesting to the fact that you have successfully completed all education and training necessary to be granted eligibility to write the NDAEB Exam and Clinical Practice Evaluation (CPE) (See theory and clinical requirements for each of the mandatory skills in this report). ***The Dental Assisting Course Work Report (DACWR) must be completed and submitted to the NDAEB for assessment along with your academic records. Refer to the ‘Applicant Credentials Assessment Submission Checklist’ above for application requirements. DENTAL ASSISTING COURSE WORK REPORT Personal Information The NDAEB certificate is an official document used in the registration/licensure of dental assistants in Canada. Your name will appear on your NDAEB certificate EXACTLY as typed below. Use only your official given name(s) and surname as they appear on your valid photo identification that you will present on the day of the exam. Do not use nicknames. If the name appearing on your academic records is different from your name as stated below, you will be asked to provide proof of name change (ex. marriage certificate, legal name change affidavit). First Name Middle Name Last Name Note: If you do not have a legal last name/surname, please enter a period (.) as a placeholder in the last name field. □ My name entered above MATCHES the name on my academic records from my dental health program. □ My name entered above DOES NOT MATCH the name on my academic records from my dental health program. **Proof of Name Change required if “DOES NOT MATCH” o Please refer to the checklist above for specific requirements. Alternate / Previous / Maiden Name (if applicable) Date of Birth (Please enter by: Year / Month / Day)
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