WPC  CJلjTw`WPwS7-d&3ڍNGJ!~DI]A0PuFB.I|1l"H5k++clČY&ރ#ALn7o,nuG݈ fR%zym4=+g.md]z}4rh3 x:byѧd\A@?g #|-.18V&#p~eRg3XX İPj7EFyU1$ {"Z3X̬R< Zw[/  (#CERTIFICATE#򀀀 $ (#򀀀   @JJ"APPLICATIONFOR j @B B  CLASS2DENTALANESTHESIACERTIFICATE  R @ @@ WESTVIRGINIABOARDOFDENTALEXAMINERS  < @TT1319RobertC.ByrdDrive | $  @%POBox1447 d  @~~CrabOrchard,_WV_Ԁ_25827_Ԉ L    Iherebymakeapplicationforacertificatetoemployoruseprocedurestoinduce   anxiolysisinthepracticeofdentistryintheStateofWestVirginiaandsubmitthefollowing   information.(INTHEEVENTTHEREISNOTSUFFICIENTSPACETOREPLY,SHOW x ANSWERATTACHEDANDONATTACHMENTSHEET,PLACEQUESTIONNUMBER ^ BEFOREANSWER.) (PLEASETYPEORPRINTLEGIBLY.)  D (#(#K(# (03 " 3"   3]2  1  .3  0    NameinFull򀀀 3]݌l(#(# Ќ     `  LAST0  0h(#(#0h(#h(#FIRST0p(#(#0p(#p(#MIDDLE0x(#(#DEGREERx(#x(# " 3"   3m2  2  .3  0    OfficeAddress򀀀 3m݌(#(# Ќ     `  NUMBERANDSTREET0  0p(#(#0p(#p(#0 (#(#SUITENUMBER (# (#    `  򀀀 x    `  CITY0 h 0h(#h(#0(#(#STATE0(#(#0 (#(#ZIPCODE` (# (#   Telephone#򀀀 .   SecondaryOffice(s),Address(es)&PhoneNumbers R    `  򀀀  !    `  򀀀 !#    `  򀀀 #^!% " 3"   32  3  .3  0    WestVirginiaDentalLicense#򀀀 p   Issued򀀀 3݌%*#'(#(# Ќ    WestVirginiaSpecialtyLicense#򀀀 p   Issued򀀀 N'$)   SpecialtyType򀀀 )&+ " 3"   32  4  .3  0    SocialSecurityNumber򀀀 3݌*(-(#(# Ќ  0  DateofBirth򀀀+t).(#(#  d/ -2 Ї@# QUALIFICATIONS  X 5.0  Iherebyqualifyforaclass2certificatetoinduceanxiolysisunderoneofthe  following:(#(#  򀀀  (a)0 ` Completionofaboardapprovedcourseofatleastsixhoursdidacticand j clinicalofeither_predoctoral_Ԁdentalschoolorpostgraduateinstruction.P` (#` (# 6.0  UNDERGRADUATEEDUCATIONt  (#(# 0  College򀀀0(#(#Location򀀀@ (#(# 0  DatesAttended򀀀to򀀀0(#(#DegreeEarned򀀀& (#(# 7.  DENTALEDUCATION   0  University򀀀0(#(#Location򀀀f(#(#   DatesAttended򀀀to򀀀  DegreeEarned򀀀 L 8.  SPECIALTYEDUCATION p 0  HospitalorUniversity򀀀<(#(# 0  Location򀀀"(#(# 0  DatesAttended򀀀to򀀀(#(# 0  DegreeorCertificateearned򀀀(#(# 0  HospitalorUniversity򀀀b(#(# 0  Location򀀀H(#(# 0  DatesAttended򀀀to򀀀.(#(# 0  DegreeorCertificateearned򀀀l(#(# 9.0  AreyoucurrentlycertifiedinHealthCareProviderBasicLifeSupport/CPR?8(#(#   򀀀yes򀀀no(Ifyes,attachcopyofcertificate.)   10.0  AreyourauxiliarypersonnelcertifiedinBasicLifeSupport/CPR?!x#(#(#   yes򀀀no(Ifyes,attachcopyofcertificate.) "^ $ 11.0  Areyourauxiliarypersonnelqualifiedasamonitortomonitorandrecordthe h%#' conditionofpatients?򀀀yes򀀀noN&#((#(#   TheBoardscompletedqualifiedmonitorchecklistisattached. )&+   򀀀yes򀀀no )', 12.0  IfurthercertifythatIhaveaproperlyequippedfacilityfortheadministrationof ,@*/ anxiolysisanditisstaffedwithasupervisedteamofauxiliarypersonnel.~-&+0(#(#   yes򀀀no d. ,1  J/,2 Ї  TheBoardscompletedfacilitychecklistisattached.򀀀yes򀀀no X 13.0  Listallinstancesofthefollowinginconnectionwithyouruseofanxiolysis,including   adetailedexplanationofanysuchoccurrence.(#(#   (a)0 ` Mortality0` (#` (#0h(#(#0h(#h(#0(#(#(b)0p(#(#Morbiditydp(#p(#   IherebycertifythatIamthepersonwhoexecutedthisapplicationforacertificate   toemployoruseprocedurestoinduceanxiolysisinthepracticeofDentistryintheState z  ofWestVirginiainconformancewithChapter30,Article4AoftheWestVirginiaCodeand ` theinformationsuppliedonthisapplicationistrueandcorrecttothebestofmyknowledge. F    `     h     򀀀 j    `     h     SignatureofApplicant P Stateof򀀀  Countyof򀀀  Subscribedandsworntobeforemethis򀀀dayof򀀀,20򀀀. \    `     h      (    `     h     NotaryPublic f MyCommissionexpires򀀀0 p 0p(#p(#0 (#(#SEAL2 (# (# PleasemakecheckormoneyorderpayabletotheWestVirginiaBoardofDental !r# Examinersintheamountof$50.00fortheapplicationfee,nopartofwhichisrefundable, "X $ andmailtotheWestVirginiaBoardofDentalExaminers,POBox1447,CrabOrchard,WV #>!% _25827_  |$$"& _@! FACILITYCHECKLIST  X   Adentistwhoinducesanxiolysisshallhavethefollowingfacilities,properly * maintainedequipmentandappropriatedrugsavailableduringtheproceduresandduring  recovery:  򀀀0 ` Anoperatingroomlargeenoughtoadequatelyaccommodatethepatienton P anoperatingtableorinanoperatingchairandtoallowanoperatingteamof  6 atleasttwoindividualstofreelymoveaboutthepatient;t  ` (#` (# ̀0 ` Anoperatingtableorchairwhichpermitsthepatienttobepositionedsothe @  operatingteamcanmaintainthepatient'sairway,quicklyalterthepatient's &  positioninanemergency,andprovideafirmplatformfortheadministration    ofbasiclifesupport; ` (#` (#  򀀀0 ` Alightingsystemwhichpermitsevaluationofthepatient'sskinandmucosal f colorandabackuplightingsystemofsufficientintensitytopermitcompletion L ofanyoperationunderwayintheeventofageneralpowerfailure;2` (#` (# ̀0 ` Suctionequipmentwhichpermitsaspirationoftheoralandpharyngeal V cavities;<` (#` (# 򀀀0 ` Anoxygendeliverysystemwithadequatefullfacemaskandappropriate  connectorsthatiscapableofdeliveringhighflowoxygentothepatientunder  positivepressure,togetherwithanadequatebackupsystem;|` (#` (# 򀀀0 ` Anitrousoxidedeliverysystemwithafailsafemechanismthatwillinsure H appropriatecontinuousoxygendeliveryandascavengersystem;.` (#` (# 򀀀0 ` Arecoveryareathathasavailableoxygen,adequatelighting,suctionand R electricaloutlets.Therecoveryareacanbetheoperatingroom; 8  ` (#` (# 򀀀0 ` Sphygmomanometer,stethoscopeandpulseoximeter; !` (#` (# 򀀀0 ` Emergencydrugs;and!x#` (#` (# 򀀀0 ` Adefibrillatordevice isrecommended . #D!%  ` (#` (#    `     h     򀀀 T&#(    `     h     SignatureofApplicant :'$)    (%* @  QUALIFIEDMONITORCHECKLIST  X   Thedentistshallmonitorandrecordthepatient'sconditionorshalluseanassistant * qualifiedasamonitortomonitorandrecordthepatient'scondition.Aqualifiedmonitor  shallbepresenttomonitorthepatientatalltimes.  򀀀0 ` Thetrainedpersonnelmusthaveacertificateshowingsuccessfulcompletion j inthelasttwoyearsofBLS/CPRtraining.(Attachacopyforourrecords)P` (#` (# 򀀀0 ` Trainedpersonnelmustbeabletomonitorthepatientsbloodpressure, t   heartrate,respirationsandoxygensaturation.Z  ` (#` (# 򀀀0 ` Trainedpersonnelmustbeabletoproperlydocumentthepatientsvital &  signs.  ` (#` (#    `     h     򀀀 f    `     h     SignatureofApplicant L