Fillable Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Ship To: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
FAX #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
#2758 (Rev. 11/20)
Wis. Stat. ch. 447 Page 1 of 2
Committed to Equal Opportunity in Employment and Licensing
DEN
TISTRY EXAMINING BOARD
ANESTHESIA OR CONSCIOUS SEDATION EDUCATION VERIFICATION FORM
APPLICANT: Complete this section and submit to the certifying body (school, Board, program, or course provider) to verify education. Form must
be returned directly from the certifying body to the Department. Note: Higher class levels encompass the authorizations of the lower levels. For
example, a dentist who holds a Class III sedation permit does not have to obtain any other sedation permit and a dentist who holds a Class II-
Parenteral permit does not need to obtain a Class II-Enteral permit.
LEVEL OF SEDATION PERMIT APPLYING FOR (select one): Class II-Enteral Class II-Parenteral Class III
Last Name First Name MI Former / Maiden Name(s)
Address (number, street, city, zip code)
Date of Birth Social Security Number (voluntary-for school’s use in locating your records)
/ /
- -
I hereby authorize the school named below to provide the Department with the information requested below.
/ /
Applicant Signature
Date
Certifying Body (school, Board, program, or course provider): Complete for one level of sedation (Class II-Enteral, Class II-Parenteral, or Class
III) as indicated by the applicant above.) Certify applicant education for the appropriate class level and return directly to DSPS. Certifying body may
fax or email with official cover sheet or letter to (608) 251-3036 or
dspscreddentistry@wisconsin.gov.
AFFIDAVIT FOR CLASS II-ENTERAL
Name of School/Board:
Location of School/Provider: (city, state)
I ATTEST TO THE FACT THAT THE ABOVE-NAMED APPLICANT (complete one option and sign and date below):
has completed a minimum of 18-hours of training in administration and management of moderate
sedation education and training that includes 20 clinical cases (which may include group observation
cases) and meets requirements under Wis. Admin. Code § DE 11.035(1). (ATTACH detailed course
content and descriptions.)
Completion Date
/ /
has completed an oral and maxillofacial surgery residency program accredited by the American
Dental Association Commission on Dental Accreditation or its successor agency.
Completion Date
/ /
is American Board of Oral and Maxillofacial Surgery certified or is a candidate for certification.
(Check appropriate box to the right.)
Certified or
Candidate for Certification
is a diplomate or candidate of the American Dental Board of Anesthesiology. (Check appropriate
box to the right.)
Diplomate or
Candidate
/ /
Signature
Date
(Print and Sign Form
)
(
Print and Sign Form)
Wisconsin Department of Safety and Professional Services
#275
8 (Rev.11/20)
Wis. Stat. ch. 447 Page 2 of 2
Committed to Equal Opportunity in Employment and Licensing
Certifying Body (school, Board, program, or course provider): Complete for one level of sedation (Class II-Enteral, Class II-Parenteral, or Class
III) as indicated by the applicant at the top of page 1.) Certify applicant education for the appropriate class level and return directly to DSPS.
Certifying body may fax or email with official cover sheet or letter to (608) 251-3036 or
dspscreddentistry@wisconsin.gov.
AFFIDAVIT FOR CLASS II-PARENTERAL
Name of School/Board:
Location of School/Provider: (city, state)
I ATTEST TO THE FACT THAT THE ABOVE-NAMED APPLICANT (complete one option and sign and date below):
has completed a minimum of 60-hours of training in administration and management of moderate
sedation education and training that includes 20 clinical cases that includes 20 clinical individually
managed cases and meets requirements under Wis. Admin. Code § DE 11.035(2). (ATTACH detailed
course content and descriptions.)
Completion Date
/ /
has completed an oral and maxillofacial surgery residency program accredited by the American
Dental Association Commission on Dental Accreditation or its successor agency.
Completion Date
/ /
is American Board of Oral and Maxillofacial Surgery certified or is a candidate for certification.
(Check appropriate box to the right.)
Certified or
Candidate for Certification
is a diplomate or candidate of the American Dental Board of Anesthesiology. (Check appropriate
box to the right.)
Diplomate or
Candidate
/ /
Signature
Date
Title
AFFIDAVIT FOR CLASS III
Name of School/Board:
Location of School/Provider: (city, state)
I ATTEST TO THE FACT THAT THE ABOVE-NAMED APPLICANT (complete one option and sign and date below):
postdoctoral residency dental program in dental anesthesiology accredited by the American Dental
Association Commission on Dental Accreditation or its successor agency.
Completion Date
/ /
has completed an oral and maxillofacial surgery residency program accredited by the American
Dental Association Commission on Dental Accreditation or its successor agency.
Completion Date
/ /
is American Board of Oral and Maxillofacial Surgery certified or is a candidate for certification.
(Check a
ppropriate box to the right.)
Certified or
Candidate for Certification
is a diplomate or candidate of the American Dental Board of Anesthesiology. (Check appropriate
box to the right.)
Diplomate or
Candidate
/ /
Signature
Date
Title
(
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Completed 11 February 2021

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