dental office experience form

This form may be printed and returned with all application materials to:
Secretary, Selection Committee
Department of Dental Hygiene
University of South Dakota
East Hall 120
414 East Clark Street
Vermillion, SD 57069

Exposure to the dental setting and observation of a dental hygienist is required for selection into the University of South Dakota Dental Hygiene Program. A minimum of 20 hours of observation is mandatory, unless you have dental assisting experience. Please return this form with your application with verification of your observation time. The hygienist(s) that you observed must sign this form. If you have dental assisting experience, please indicate the names and dates of the dentists for whom you worked and, if applicable, the name of the dental assisting program from which you graduated and a copy of any diploma or certificate that you hold.

Note to applicants: You will need to schedule an observation appointment, to thank the dental health care practitioners for the opportunity to observe them, and make sure you show up on time for your observation appointment. Wear appropriate attire and conduct yourself professionally. Understand that all information about patients, whether dental or personal, is absolutely confidential and you should not discuss or repeat anything that you see, read, or hear.

Verification of Dental Office Observation

________________________ observed in my clinic on the following dates:
   (Applicant's Name)

Observation time may be spent in The University of South Dakota Department of Dental Hygiene campus clinic as well as in a private dental office. If your observation is done at USD, please have an instructor in the clinic sign this form.