2017 DENTAL HYGIENE PROGRAM APPLICATION FORM
Print or type — All items MUST be completed for your application to be considered.
Full Name: ___________________________________________________________________________
Last First Middle
Address: _____________________________________________________________________________
Street/PO Box
Address: _____________________________________________________________________________
City State ZIP
Phone: ( ) Other Phone: ( )
Email: Birth Date:
Step 1
Submit an LCCC Admission Application to the
Admissions Office. It is the student’s responsibility
to request official transcripts of high school and
college courses to be sent to the Student Records
Office. NOTE: Unofficial transcripts (student copies,
including LCCC) must be attached and submitted
with the Dental Hygiene Application.
All Institutions Previously attended:
Copies of student college transcripts, including
LCCC, showing all completed course work must
be received at the time of application. Courses
completed by August 15, 2016 for the summer
session, will be considered for application points, if
student copies of transcripts or grade are received by
August 25, 2016 in the Dental Hygiene Department.
Transcripts or grade reports of any course work
completed during the fall semester must be received
by December 16, 2016 in the Dental Hygiene
Department. It is the student’s responsibility to have
official transcripts mailed to the Student Records
Office. Failure to have all official prerequisite
transcripts at the Student Records Office can
jeopardize timely graduation.
I have received information on the Dental Hygiene
calendar and I understand that the Dental Hygiene
Program fee does not include tuition or other college
fees.
______________________________________________
Name Date
______________________________________________
Signature
Step 2
Prerequisites:
Completion of/or substantial progress in completing,
all required prerequisites as outlined in the program
application. All must be completed with a “C” or
higher by December 16, 2016:
Step 3
Complete the Dental Hygiene program’s admission
form. Include the signed Bloodborne Pathogen Policy
with your application. Applications will be accepted
after July 1, 2016 and must be received on or
before August 15, 2016. Prerequisite courses must
be completed, in progress or the student must be
enrolled for the fall semester to be able to complete
all prerequisite courses prior to acceptance into
the dental hygiene program. All courses completed
by the application deadline will be awarded points
according to the attached criteria. For points to be
awarded for completed summer semester courses,
students must submit a copy of unofficial transcripts,
grade reports or verification by the course instructor
to the dental hygiene program on or before August
25th. Official transcripts must also be requested and
sent to the Student Records office.
Step 4
If the applicant is accepted into the program, proof
of the following additional requirements must be
submitted to the dental hygiene program by the dates
stipulated in the conditional acceptance letter:
a. Documentation of LCCC application and
acceptance for Admission to the institution.
Applicants must request and send official
transcripts from high school and from each college
previously attended. GED recipients must request
an official score report and have it sent. NOTE:
Student copies of the college transcripts must be
attached and submitted with the Dental Hygiene
Program Application.
b. Completed acceptance form
c. Dental Hygiene Program fee deposit of $3,375.00
d. Verification of current vaccinations and titers
(Hepatitis B, Rubella, Rubeola, Diptheria, Tetanus,
MMR, Varicella). A current TB test (PPD) will need
to be completed prior to beginning clinic in March.
Students must maintain current TB testing at all
times while in the Dental Hygiene Program.
e. A copy of both sides of a current American
Heart Association certification card in Cardio
Pulmonary Resuscitation for Health Care Providers.
(Note: Other organization’s certification is NOT
acceptable.) Students must maintain current
Health Care Provider CPR certification at all times
while in the Dental Hygiene Program.
f. A verification form related to personal health
insurance. All students admitted to the Dental
Hygiene Program are expected to be responsible
for personal health costs. Students are not covered
by worker’s compensation because they are not
employees of LCCC or any clinical sites.
g. Acceptable chemical impairment screening
and criminal background checks are required.
Chemical impairment may compromise both
the educational process and patient safety. Early
identification, evaluation and treatment are in
the best interest of our students and the patients
they serve. In addition, clinical sites may require
random drug testing and/or drug testing for
reasonable cause. Generally, the urine drug test
screens for alcoholic beverages, illegal drugs, or
drugs that impair judgment while in the clinical
site, classroom or participating in program
activities. Testing positive on the screening, or
evidence of tampering with a specimen, will
disqualify a student from participating in program
assignments.
Dental health professionals may be exposed to blood
borne pathogens/contagious diseases, therefore,
strict compliance with Centers of Disease Control
(CDC) and OSHA standards are maintained.
Although diseases may be encountered, research
indicates that risks are negligible when optimal
infection control is practiced. Policies on blood borne
and infectious diseases are available upon request
from the Dental Hygiene Program.
In addition to drug screening, for the safety of
patients and health care workers, child abuse
clearance and criminal background checks are
required prior to a clinical assignment. Certain
criminal activity as evidenced by a criminal
background check may also disqualify a student from
clinical participation.
Students are advised that the inability to gain clinical
education experiences can result in the inability to
meet program objectives and outcomes. These
circumstances may prevent final acceptance into and/
or progression through the program, and ultimately
result in dismissal from the program.
The complete Chemical Impairment and Background
Check Policy is available online and from the
Dental Hygiene Director and will be explained
during orientation. Every student admitted to the
program will be required to abide by the policy and
acknowledge agreement with the policy in order to be
accepted into the program.
The courses listed below are all of the general education requirements
for acceptance to the Dental Hygiene Program.
Course Number Title Credit Hours Clock Hours
COLS 1000 Intro to College Success
1
3 hrs 45 hrs
ENGL 1010 English I: Composition
3 hrs 45 hrs
MATH 1400 College Algebra
2
3 hrs 45 hrs
SOC 1000 Sociological Principles
3
3 hrs 45 hrs
PSYC 1000 General Psychology
3 hrs 45 hrs
CO/M 2010 Public Speaking
4
3 hrs 45 hrs
EITHER:
^*ZOO 2015 Human Anatomy -AND-
4 hrs 75 hrs
^*ZOO 2025 Human Physiology -OR-
4 hrs 75 hrs
^*ZOO 2010 Anatomy and Physiology I -AND-
4 hrs 75 hrs
^*ZOO 2020 Anatomy and Physiology II
4 hrs 75 hrs
*MICR 2240 Medical Microbiology
4 hrs 75 hrs
+POLS 1000 American & WY Government -OR-
+HIST 1211 US History to 1865 -OR-
+HIST 1221 US History from 1865 -OR-
+HIST 1251 Wyoming History -OR-
+ECON 1200 Economics, Law, and Govt.
3 hrs 45 hrs
Total Hours 30-33 hrs 690 hrs
The courses listed below are all of the general education requirements for graduation from the
Dental Hygiene Program. Please list which courses you are enrolled in as well as the courses
you have completed.
Course Course # Course Name Institution Semester Grade
COLS 1000
Intro to College Success
1
ENGL 1010
English I: Composition
MATH 1400
College Algebra
2
SOC 1000
Sociological Principles
3
PSYC 1000
General Psychology
CO/M 2010
Public Speaking
4
EITHER:
^*ZOO 2015
Human Anatomy -AND-
^*ZOO 2025
Human Physiology -OR-
^*ZOO 2010
Anatomy and Physiology I
-AND-
^*ZOO 2020
Anatomy and Physiology II
*MICR 2240
Medical Microbiology
+POLS 1000
American & WY Government
-OR-
+HIST 1211
US History to 1865 -OR-
+HIST 1221
US History from 1865 -OR-
+HIST 1251
Wyoming History -OR-
+ECON 1200
Economics, Law, and Govt.
NOTE: You cannot register for any dental hygiene class until you are notified of official
acceptance or have written permission from the Program Director.
DENTAL HYGIENE ADMISSIONS WORKSHEET
The Dental Hygiene Admissions Worksheet is used by the
Dental Hygiene staff to rank the applicants for acceptance purposes.
Applicant Name ________________________________________________________________________________
Science Grade Point Average
The science GPA is based on all science courses that apply toward the Dental Hygiene Program. All courses
must be completed with a grade of C or better. For courses that have been retaken, the most recent grade will
be used in the calculation of the GPA. A minimum GPA of 2.5 is required for all science courses to obtain
points.
Science GPA ________
0.75 points will be awarded for every 0.05 points over the minimum 2.5 GPA requirements
Points Awarded ________
2.55=0.75pt
2.6=1.5pts
2.65=2.25pts
2.7=3pts
2.75=3.75pts
2.8=4.5pts
2.85=5.25pts
2.9=6pts
2.95=6.75pts
3=7.5pts
3.05=8.25pts
3.1=9pts
3.15=9.75pts
3.2=10.5pts
3.25=11.25pts
3.3=12pts
3.35=12.75pts
3.4=13.5pts
3.45=14.25pts
3.5=15pts
Two points will be awarded for each of the following science prerequisite courses completed with a grade of C
or higher prior to application: Anatomy ______
Physiology ______
Medical Microbiology ______
(6 points max) Points Awarded ________
General Studies Grade Point Average
The general studies GPA is based on all general study courses that apply toward the Dental Hygiene Program.
All courses must be completed with a grade of C or better. For courses that have been retaken, the most
recent grade will be used in the calculation of the GPA.
A minimum GPA of 2.5 is required for all general study prerequisites to obtain points.
General Studies GPA ________
0.5 points will be awarded for every 0.05 over the minimum 2.5 GPA requirement of the general studies
prerequisites (not including science prerequisites factored in above).
Points Awarded ________
2.55=0.5pt
2.6=1pt
2.65=1.5pts
2.7=2pts
2.75=2.5pts
2.8=3pts
2.85=3.5pts
2.9=4pts
2.95=4.5pts
3=5pts
3.05=5.5pts
3.1=6pts
3.15=6.5pts
3.2=7pts
3.25=7.5pts
3.3=8pts
3.35=8.5pts
3.4=9pts
3.45=9.5pts
3.5=10pts
3.55=15.75pts
3.6=16.5pts
3.65=17.25pts
3.7=18pts
3.75=18.75pts
3.8=19.5pts
3.85=20.25pts
3.9=21pts
3.95=21.75pts
4=22.5pts
(22.5 points max)
3.55=10.5pts
3.6=11pts
3.65=11.5pts
3.7=12pts
3.75=12.5pts
3.8=13pts
3.85=13.5pts
3.9=14pts
3.95=14.5pts
4=15pts
(15 points max)
One point will be awarded for each of the following general education pre-requisite courses competed with a
grade of C or higher prior to application: English I: Composition ______
Algebra/Problem Solving ______
Sociological Principles ______
General Psychology ______
Speech/Interpersonal Comm. ______
(5 points max) Points Awarded ________
Points Awarded (48.5 points max) ________
Deduction for 3 or more repeated courses ________
Total Points Awarded ________
LARAMIE COUNTY COMMUNITY COLLEGE
DENTAL HYGIENE BLOODBORNE PATHOGEN
STATEMENT AND POLICY
The LCCC dental hygiene clinic adheres to the
recommended guidelines set forth by the ADA
and the CDC. The dental hygiene clinic follows all
standard precautions such as HBV vaccination,
hand washing, protective barriers and the disposal
of needles and other sharp instruments in a
safe manner.
When precautions are followed, patients infected
with bloodborne pathogens can be treated safely in
the dental setting. According to the CDC, there is no
significant risk of contracting bloodborne diseases
through the provision of dental treatment. Standard
precautions is an effective means of reducing
bloodborne pathogen transmission.
Dental hygiene students are advised to be up to date
on all vaccines and receive the hepatitis B vaccination
series and titer verification, to protect themselves and
their patients from infectious organisms.
Patients seen in the dental hygiene clinic who may be
infected with a bloodborne pathogen are entitled to
dental hygiene treatment. A dental hygiene student
may not refuse to provide dental hygiene services
based upon a patient’s medical status.
Dental professionals are obligated to protect the
confidentiality of patient records and to maintain
those records. A patient’s bloodborne pathogen
status and medical condition may only be shared with
the patient’s other health care providers as allowed by
state and federal law.
All dental hygiene students have an ethical obligation
to immediately inform any patient they suspect may
have been exposed to blood or other infectious
material while seen in the dental hygiene clinic. As
required by law, infected dental health care workers
must practice in compliance with CDC.
Current evidence indicates that there is no significant
risk of contracting bloodborne diseases through
dental hygiene treatment when standard precautions
are routinely followed. All dental hygiene students
are strongly urged to undergo a medical physical to
determine their bloodborne pathogen status. Those
students who believe they are at risk for bloodborne
pathogen infection should regularly monitor their
status. All health care workers testing positive for
a bloodborne pathogens must practice only in
strict compliance with the current infection-control
recommendations of the CDC for infected providers
as required by law.
If an exposure in the dental hygiene clinic were to
occur, the student would be sent for a post exposure
evaluation and the patient would be referred to
a qualified medical practitioner to provide post
exposure services.
* adapted from the ADA Bloodborne Pathogen, CDC guidelines and OSHA policy
I have read and understand LCCC’s Bloodborne Pathogen Statement and Policy.
Name (Print)
Signature Date
***Please return this form with your dental hygiene application packet.
PERSONAL DENTAL HYGIENE ADMISSION CHECKLIST
DATE COMPLETED
LCCC Institutional Application of Admission __________________________
Requested and sent official transcripts from
previously attended colleges to Student Records
with LCCC application; __________________________
Requested and sent official transcripts
from high school
-OR-
Requested and sent official score report of
Your GED transcript (transfer applicants only) __________________________
Student (unofficial) copies attached to this application __________________________
Institution: ___________________________ __________________________
Institution: ___________________________ __________________________
Institution: ___________________________ __________________________
Institution: ___________________________ __________________________
Pre-admission observations
Observation 1 __________________________
Observation 2 __________________________
Read, understood, signed and included with application –
Infection Control/Bloodborne Pathogen Policy __________________________
Dental Hygiene Application submitted __________________________
Read and understood
Chemical Impairment Background Check Policy __________________________
__________________________________________________
PRINT NAME
__________________________________________________ ______________________
SIGNATURE DATE
DENTAL HYGIENE PROGRAM
Pre-Admission Observation
EVALUATION FORM
To be admitted to the Dental Hygiene Program, a student must have done an observation with 2 different
dental hygienists totaling 8 hours. We believe that the prospective student will have a better understanding of
the type of work that a dental hygienist does by attending these observation periods.
The faculty of the Dental Hygiene Program would like to thank you and your staff for the consideration you
have shown to this prospective student and appreciate your comments.
Please answer the following questions in regards to the observation of the prospective student and mail to the:
Dental Hygiene Program
LCCC
1400 E. College Drive
Cheyenne, WY 82007
Name of facility:
______________________________________________________________
Name of prospective student: ___________________________________________________
Number of hours spent in the office: _____________________________________________
Date(s) of attendance: _________________________________________________________
The Student
YES NO
Called to make an appointment
Was punctual
Came to the office properly groomed/attired
Displayed a professional demeanor
Appeared interested in dental hygiene procedures
Other comments and overall impressions:
________________________________________ __________________
Signature of Dental Hygienist Date
Thank you for your assistance!
DENTAL HYGIENE PROGRAM
Pre-Admission Observation
EVALUATION FORM
To be admitted to the Dental Hygiene Program, a student must have done an observation with 2 different
dental hygienists totaling 8 hours. We believe that the prospective student will have a better understanding of
the type of work that a dental hygienist does by attending these observation periods.
The faculty of the Dental Hygiene Program would like to thank you and your staff for the consideration you
have shown to this prospective student and appreciate your comments.
Please answer the following questions in regards to the observation of the prospective student and mail to the:
Dental Hygiene Program
LCCC
1400 E. College Drive
Cheyenne, WY 82007
Name of facility:
______________________________________________________________
Name of prospective student: ___________________________________________________
Number of hours spent in the office: _____________________________________________
Date(s) of attendance: _________________________________________________________
The Student
YES NO
Called to make an appointment
Was punctual
Came to the office properly groomed/attired
Displayed a professional demeanor
Appeared interested in dental hygiene procedures
Other comments and overall impressions:
________________________________________ __________________
Signature of Dental Hygienist Date
Thank you for your assistance!