Dental Assistant Lab Supervisor Skills Survey
Name: ______________________________________________ Date: _______________________
Position: __________________________________________________________________________
This information becomes part of your application. Your skills, expertise, and education will be rated based on
your answers. Please fill out this form as completely as possible. Under columns three through six, check the
category that best shows the depth of your experience. Do not check more than one column per line.
Years of relevant experience:
Check Degrees (Attach Transcripts):
Full time work
HS/GED
Part time work
Certificate
Area
Associate
Major
Bachelor
Major
Model/
Version
Used
Years of
Experience
Training
only
Preformed
with help
Performed
unaided
Instructed
others
Dental Office Skills:
Emergency Treatment of Dental Injuries
Develop Safe Environment for Clients
Maintain Safe Environment for Clients
Enforce OSHA Standards & Aseptic
Standards
Chair Side Procedures
Dental Instruments/Instrumentation
Basic Tray Set-ups
Clean Dental Equipment Techniques
Ensure Operation of Dental Equipment
X-Ray Product Knowledge
Conserving Dental Resources
Maintaining Supply Inventory
Amalgam Procedures
Composite Procedures
Crown & Bridge Procedures
Endodontics
Oral Surgery
Rubber Dam Procedures
Material Mixtures
Supply Orders
2
Dental Assistant Lab Supervisor Skills Survey
Model/
Version
Used
Years of
Experience
Training
only
Preformed
with help
Performed
unaided
Instructed
others
Equipment:
Autoclave
Ultrasonic Cleaner
Panoramic X-Ray Machines
Standard X-Ray Machines
Dental Chairs
Central Air & Vacuum Systems
Triad
Automatic Processor
Manual Processor
Lab Engines
Lathe
Model Trimmer
Current CPR Certification
Other:
I
have answered the above information to the best of my knowledge.
S
ignature: ______________________________________________ Date: ________________________
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signature
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