WEST VIRGINIA BOARD OF DENTAL EXAMINERS

                                                                                1319 Robert C. Byrd Drive

APPLICATION FOR DENTAL HYGIENIST LOCAL ANESTHESIA PRIVILEGES

            NAME:

            ADDRESS:

            SOCIAL SECURITY NUMBER:

I.                   Current WV License #

II.                  Current Health Care Provider BLS/CPR (Must attach documentation)

III.                 Successful completion of WV Board of Dental Examiner sanction course in local anesthesia administration. (Must attach documentation unless previously provided and approved by the Board)

IV.                Passage of NERB Dental Hygiene Local Anesthesia examination or equivalent regional or state examination. This test must be taken within 12 months of course completion or it will be necessary to repeat the course. (Must have scores sent directly to the Board office by the examination entity)

            All four points of this application must be satisfied before local anesthesia privileges can be granted. Local anesthesia administration by a dental hygienist 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.

            APPLICATION FEE: $25.00