LARA/BPL-DENTRDAFUNCTIONS (10/18)
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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 335-0918
www.michigan.gov
/bpl
BPLHelp@michigan.gov
VERIFICATION OF 35 HOURS OF SPECIFIC R.D.A. FUNCTIONS TRAINING
Authority: 1978 PA 368
This certification form must be submitted directly to this office by the R.D.A. school where the 35 hours of specific R.D.A.
functions was completed. This form is only required for individuals who completed their Michigan R.D.A. educational
program prior to March 2004 or individuals who completed their dental assisting education outside of Michigan
.
Section of Form to be Completed by Applicant:
Applicant’s Name (First, Middle, Last)
Date of Birth
Name of School
\
Date of Completion
Applicant’s Signature
Date
Remainder of Form to be Completed by R.D.A. School:
CERTIFICATION AND SIGNATURE
I cer
tify the applicant named above has completed instruction as follows:
A cour
se in the assisting and monitoring of the administration of nitrous oxide analgesia containing a minimum of 5 hours
of didactic instruction and includes content in all of the following nitrous oxide analgesia medical emergencies techniques,
pharmacology of nitrous oxide, and nitrous oxide techniques.
A cour
se with a minimum of 20 hours didactic instruction followed by a comprehensive clinical experience of sufficient
duration that validates clinical competence through a criterion based assessment instrument for taking final impressions
and placing, condensing, and carving amalgam restorations.
For per
forming intraoral dental procedures a course containing a minimum of 10 hours of didactic and clinical instruction
in performing pulp vitality testing, placing and removing matrices and wedges, applying cavity liners and bases, placing
and packing nonepinephrine retraction cords, applying desensitizing agents, taking an impression for orthodontic
appliances, mouth guards, bite splints, and bleaching trays, drying endodontic canals with absorbent points and etching
and placing adhesives prior to placement of orthodontic brackets.
_____________________________________________
___ _______________________________________
Authorized Signature Date
________________________________________________
Print/Type Name and Title (Seal)
