Voluntary Disclosure of Personal Information Form

NDAEB - Revised January 2019 VOLUNTARY DISCLOSURE OF PERSONAL INFORMATION TO DA ASSOCIATION OR THIRD PARTY (OTHER THAN A CDARA) With your voluntary consent, the NDAEB will release your name, NDAEB certificate number and date of exam or CPE sitting to a dental assisting association or other third party (one only). Should you wish to have the NDAEB voluntarily release your name, NDAEB certificate number and date of examination or CPE to a provincial DA association, or third party other than a CDARA, you must read and voluntarily sign the consent form below. Releasing your name and NDAEB certificate number does not mean that you are automatically licensed/registered/certified in a province. You must contact the CDARA or DA association for details regarding provincial licensure/registration requirements. Please note, in the event you are unsuccessful on your exam or CPE, the NDAEB will not release your information to a third party, EXCEPT FOR A CDARA, even if you have signed this consent form. You may voluntarily disclose your NDAEB information, directly to a third party without the knowledge of the NDAEB. Please retain your exam and CPE results and NDAEB certificate in a safe place for future use. You are not required to sign this form when registering for the exam or CPE . Should you wish to have the NDAEB disclose information on your behalf at a later date, you may request a form at some time in future. Note: in the interest of public safety, the NDAEB will automatically release your exam or CPE results, pass or fail, to the Canadian Dental Assisting Regulatory Authority in the province in which you wrote the exam or took the Clinical Practice Evaluation (CPE) or to another provincial CDARA upon request of the CDARA. Please refer to the written exam or CPE application form and NDAEB privacy policy for details. VOLUNTARY INFORMED CONSENT I request that the NDAEB disclose my name, certificate number and date of exam and or CPE to one of the following: Please check  one only ❑ Ontario Dental Assistants’ Association (ODAA) ❑ Other ( please specify below): Signature: ________________________________ Date: _ ____________ Name: (Please print) ___________________ _______________________ 204-2283 St. Laurent Blvd. Ottawa, Ontario K1G 5A2 Tel: (613) 526-3424 Fax: (613) 526-5560 Email: [email protected]