Form 2b - Verification Of Post-Doctoral Education In Use Of Parenteral Conscious Sedation Page 2
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2SECTION II:
VERIFICATION OF POST-DOCTORAL EDUCATION IN USE OF PARENTERAL CONSCIOUS SEDATION
INSTRUCTIONS TO INSTITUTION: Please complete this section and return directly to the Division of Professional Licensing Services. It
will not be accepted if incomplete or if returned by the applicant.
I hereby certify that __________________________________________________________________ completed ____________ hours
(Dentist's Name)
of post-doctoral education in the use of parenteral conscious sedation in a program accredited/approved by _______________________
(Accrediting body such as CDA)
__________________________________________ at _________________________________________________________________
(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:
Patient evaluation
Yes
No
Monitoring, management of emergencies
Yes
No
Management of airway
Yes
No
Pharmacology
Yes
No
Control of pain and anxiety
Yes
No
On the chart below, list other subjects included in training.
Other Subjects
Total Clock Hours (Minimum 60 hours): ___________
If necessary, attach additional sheets.
In addition, this individual successfully administered parenteral conscious sedation on _______________ patients (minimum 20).
(number of patients)
Please check and attach a letter of explanation with this form if this dentist did not successfully complete the 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 or official position: ___________________________________________________
Institution: ______________________________________________________________
(INSTITUTION SEAL)
(If seal not available, attach explanation)
Address: _______________________________________________________________
Telephone number: ( __________ ) __________________________________________
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 2B, Page 2 of 2, Rev. 11/05
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