Application for Nitrous Oxide Monitoring Certificate

Applicant’s Name: ____________________________________

Address: _______________________________________________ _______________________________________________________

Phone Number: ___________________________

1)  Two (2) hours of didactic instruction.

Course Title and date: ________________________________

Location: _______________________________________

Hours: __________

Instructor: _______________________________

Instructor’s Signature: _________________________

Date: _____________

2)  Upon completion of the course, the applicant must pass a written examination with a minimum score of seventy-five (75%).

Written Score: ____________

Instructors Signature: _________________________________

Date: ______________

3)  The course content must include, but not limited to the subjects listed in the nitrous oxide monitoring requirements document available from the West Virginia Board of Dental Examiners office or on the website www.wvdentalboard.org.

4)  Provide proof of current certification in health care provider CPR through the American Heart Association or the American Red Cross (Must attach documentation)

A course syllabus must be submitted with the application to determine if this requirement has been satisfied unless previously provided and approved by the Board.

All four points of this application must be satisfied before nitrous oxide certificate is issued. Nitrous Oxide monitoring by a dental hygienist/dental assistant must be delegated by the supervising dentist under direct supervision.

Completion of a board approved course and examination does not authorize you to practice these privileges until your application is completed and a certificate is received from the Board office

            WV Board of Dental Examiners, PO Box 1447, Crab Orchard, WV  25827                                              

            Application Fee $25.00