Application For Dental Hygienist Licensure - Delaware Board Of Dentistry And Dental Hygiene Page 6
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9DISCLOSURES – All applicants complete this section.
16. Have you engaged in the illegal use of controlled dangerous substances within that past two years? Yes
No
If
yes, continue to Question 17. If no, skip to Question 18.
17. Are you currently participating in a supervised rehabilitation program or professional assistance program that monitors
you in order to assure that you are not illegally using controlled substances?
Yes
No
If yes, explain fully:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
18. Have you ever been denied a DEA (Narcotic) registration number? Yes
No
Current DEA #______________
If yes, submit a letter explaining fully.
19. Has your professional license ever been subjected to disciplinary action (including but not limited to consent
agreements, fines, probation, suspension or revocation)? Yes
No
If yes, submit a letter explaining fully.
Include an official Board order or other documents.
20. Has any malpractice action been brought against you in the past five years? Yes
No
If yes, enclose a list on
a separate sheet of paper. Include dates, disposition and amount of awards or settlements, if any.
21. Are any disciplinary or ethical complaints currently pending against you? Yes
No
If yes, submit a letter fully
explaining. Include copies of all official documents or Board orders.
22. Are you physically or mentally incapable of engaging in the practice of dental hygiene according to generally accepted
standards? Yes
No
If yes, continue with Question 23. If no, skip to the
section.
DUTY TO REPORT
23. Do you agree to submit to an examination to determine such capability as the Board may deem necessary?
Yes
No
Complete the Criminal History Record Check Authorization form to request State of Delaware and Federal Bureau
of Investigation criminal background checks. Follow the instructions on the authorization form to arrange to be
fingerprinted.
DUTY TO REPORT– All applicants complete this section.
24. To obtain a license in Delaware, you must certify that you understand that you have a mandatory obligation to self
report any of the following within 30 days:
•
Any arrest or the bringing of an indictment or information charging you with a crime substantially related to the
practice of dentistry and dental hygiene as defined in Section 11.0 of the Board’s Rules and Regulations.
•
Any conviction, including any verdict of guilty or plea of guilty or no contest, of any crime substantially related to
the practice of dentistry and dental hygiene as defined in the Section 11.0 of the Board’s Rules and Regulations.
I certify that I have read and understand all provisions in the Delaware Dental Practice Act
including
24 Del. C. §1131
,
and the
Rules and Regulations
listed above, and that I understand my duty to self report. Yes
No
25. To obtain a license in Delaware, you must certify that you understand that you have a mandatory obligation to make
an immediate oral report to the to the Department of Services for Children, Youth and Their Families if you know of, or
you suspect, child abuse or neglect under Chapter 9 of Title 16 and to follow up with any requested written reports.
I certify that I have read and understand
16 Del. C. §903
and that I understand my duty to report. Yes
No
26. You have a mandatory duty to file a written report with the Division of Professional Regulation within 30 days if you
reasonably believe that any other dental or dental hygiene practitioner or any other healthcare practitioner, including
any person licensed to practice medicine in Delaware:
•
has engaged in or is engaging in conduct that would constitute grounds for disciplinary action
•
may be unable to practice with reasonable skill and safety to the public due to mental illness or mental
incompetence, physical illness (including deterioration through the aging process or loss of motor skill), or
excessive abuse of drugs (including alcohol)
•
is excessively using or abusing drugs including alcohol.
I certify that I have read and understand the provisions of
24 Del. C. §1131A
and that I understand my duty to report.
Yes
No
Revised 9/2017
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