Form 2c - For An Enteral Conscious Sedation Certificate (Page 2 of 2) in pdf

SECTION II: VERIFICATION OF TRAINING

INSTRUCTIONS TO INSTITUTION OR PROVIDER : Please complete this section and return directly to the Division of Professional

Licensing Services. It will not be accepted if it is incomplete or if it is returned by the applicant.

I hereby certify that ___________________________________________________________________ completed ____________ hours

(Dentist's Name)

of pre-doctoral or post-doctoral education in the use of enteral conscious sedation in a program accredited/approved by

_______________________________________ at _____________________________________________________________________

(Accrediting body)

(Name and location of institution)

_____________________________________________________________________________________________________________

Inclusive dates of training _____________ to _____________

Type of residency program completed (if applicable): ___________________________________________________________________

(e.g. GPR, AEGD, OMS, etc.)

The training included instruction in all of the following required subjects:

Nitrous oxide use

Yes

Emergency management

Yes

On the chart below, list other subjects included in training.

Other Subjects

Total Clock Hours (Minimum 18 hours): ___________

If necessary, attach additional sheets.

In addition, this individual successfully administered or observed enteral conscious sedation on _______________ patients (minimum 20)

(number of patients)

Please check here and attach a letter of explanation with this form if this dentist did not successfully complete the

pre-doctoral or post-doctoral training program.

ATTESTATION

I hereby attest that to the best of my knowledge and belief the foregoing is a true statement.

Signature:______________________________________________________________ Date: _______ / _______ / _______

mo.

day

yr.

Print or type name: ______________________________________________________

Title: __________________________________________________________________

(INSTITUTION SEAL)

Institution or provider: ____________________________________________________

(If seal not available, attach explanation)

Telephone: ( __________ ) __________________________________

Fax: ( __________ ) _________________________

E-mail: ________________________________________________________________

Return Directly to:

New York State Education Department, Office of the Professions, Dentistry Unit, 89 Washington Avenue,

Albany, NY 12234-1000.

Dental Anesthesia/Sedation Certification Form 2C, Page 2 of 2, Rev. 11/05

Form 2c - For An Enteral Conscious Sedation Certificate Page 2