Employment Verification Form printable pdf download

EMPLOYMENT VERIFICATION FORM

PLEASE PRINT:

Name of Employer/Dentist: _____________________________________Dentist’s License Number _______________

Address: _________________________________________________________________________________________

Phone Number: ______________________________________________Fax Number: __________________________

Name of Employee: __________________________________________ Phone Number: ________________________

Address: _________________________________________________________________________________________

I HEREBY ATTEST THAT THE ABOVE NAMED EMPLOYEE HAS BEEN IN MY EMPLOYMENT FOR (Check one):

At least 400 hours of clinical dental assisting experience in preparation for Preliminary Oral Inspection course.

At least 400 hours of clinical dental assisting experience and has taken Preliminary Oral Inspection course.

Employee is applying for the following courses:

____Preliminary Oral Inspection

____Dental Sealants

____ Monitoring Nitrous Oxide Administration

____ Dental Radiology

____ In-Office Whitening

____Expanded Orthodontic Duties

____ Coronal Polishing

____Taking Impressions

____Temporary Crown & Bridge Fabrication

During the tenure of employment, I further attest to the fact that I have personally trained or can verify that the

candidate has been trained in the following areas. If this dental assistant does not perform all of these functions in

the office, she/he must still possess a basic understanding of them in order to increase his/her likelihood of success in

the workshops provided by NHTI. (Check all that apply)

Infection control & proper hand washing technique

HIPPA and confidentiality

Aseptic technique and preventing cross-contamination

Importance of medical history documentation

Equipment disinfection and sterilization methods

Importance of treatment documentation

PPE (Personal Protective Equipment)

Patient management techniques

Standards and guidelines of occupational safety for

Knowledge of proper plaque control techniques

dental office personnel

Use, handling & characteristics of dental materials

Assisting with intraoral procedures

Processes and procedures for the laboratory

Four-handed dentistry techniques

Radiation safety for patient and operator

Signature of Licensed Dentist/Employer: ___________________________________Date: ____________________

Please return by mail to: Business Training Center, Farnum Hall

Or fax to: (603)230-9304

NHTI, Concord’s Community College

31 College Drive, Concord, NH 03301-7412

Employment Verification Form

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