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NEVADA STATE BOARD of DENTAL EXAMINERS Committee on Dental Hygiene & Dental Therapy & Subcommittee Teleconference Meeting Wednesday, December 23, 2020 5:30 p.m. PUBLIC BOOK

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  • NEVADA STATE BOARD of

    DENTAL EXAMINERS

    Committee on Dental Hygiene &

    Dental Therapy & Subcommittee

    Teleconference Meeting

    Wednesday, December 23, 2020

    5:30 p.m.

    PUBLIC BOOK

  • Agenda Item (4)(a)Public Health Dental Hygiene and

    Dental Therapy Subcommittee Member: Antonina Capurro, DDS

    Public Book Page 2

  • Antonina Capurro, DMD, MPH, MBA

    MAILING ADDRESS:

    PHONE:

    EMAIL:

    EDUCATION:

    Current Dental Public Health Residency Program

    A.T. Still University

    05/2016 Degree: Master of Business Administration

    University of Nevada Las Vegas, Las Vegas, NV

    05/2012 Degree: Master of Public Health

    Concentration in Health Care Administration and Policy

    University of Nevada Las Vegas, Las Vegas, NV

    05/2011 Degree: Doctor of Dental Medicine

    University of Nevada Las Vegas School of Dental Medicine, Las Vegas, NV

    05/2005 Degree: Bachelor of Science in Biochemistry/Minor in Psychology

    University of Nevada Las Vegas, Las Vegas, NV

    05/2003 Degree: Associate of Science in Biotechnology

    College of Southern Nevada, Las Vegas, NV

    DENTAL LICENSURE:

    Nevada #LL-384-14

    CERTIFICATIONS:

    Dates Certification Organization

    2018-Present CPR UNLV School of Dental Medicine

    2014-Present Laser Training UNLV School of Dental Medicine

    2010-Present Nitrous Oxide UNLV School of Dental Medicine

    CURRENT APPOINTMENT:

    Position: Nevada Division of Public and Behavioral Health, State Dental Health Officer

    and UNLV School of Dental Medicine, Visiting Assistant Professor

    Tenured or Non-Tenured: Non-tenured

    Date Hired: August 2016 and July 2012

    EMPLOYMENT HISTORY/FACULTY APPOINTMENTS:

    08/16-Present Nevada State Dental Health Officer NV DHHS, DPBH

    07/12-Present Visiting Assistant Professor UNLV SDM, Las Vegas, NV

    05/11-07/12 Part-time Clinical Faculty UNLV SDM, Las Vegas, NV

    04/09-05/11 ER Student Dentist UNLV SDM, Las Vegas, NV

    11/05-08/06 Pharmacy Technician St. Francis Hospital, Memphis, TN

    05/02-08/02 NIH/NSF Researcher UNR, Reno, NV

    Public Book Page 3

  • AWARDS & CERTIFICATES

    American Dental Association’s 2018 10 Under 10 Award

    Lee Business School Medallion Program Recipient 2016

    Certificate of Recognition from the UNLV SDM Class of 2014

    Nominated to America’s Top Faculty, Faculty Row’s Network

    International Association of Coroners and Medical Examiners Forensic Odontology Training Certificate

    Fellowship status in the International Academy for Dental-Facial Esthetics

    STATE DENTAL HEALTH OFFICER (NRS. 439.272) for the Division of Public and Behavioral Health

    Created in 2015 and established in statute, the State Dental Health Officer oversees the Nevada Oral Health

    Program, affiliated staff, and associated budgets. Job duties include gathering oral health surveillance data,

    providing subject matter expertise across all divisions within the Nevada Department of Health and Human

    Services, making recommendations to the Legislature, and revising and creating state policies that will expand

    access to quality oral health care services for all Nevadans. Detailed position reports and Oral Health Program

    activities are presented to the Advisory Committee on the State Program for Oral Health, NRS 439.2792, on a

    quarterly basis. Position highlights include:

    Author of BDR 40-455 which revises provisions governing dentistry for teledentistry, dental emergency

    responders, and dental insurance transparency. Bill language was adopted for sponsorship by the Legislative

    Committee on Health Care (NRS 439B.200) and will be heard in the 81st(2021) Legislative Session.

    Created statewide plan for resumption of non-emergency dental services during the COVID-19 pandemic

    which was adopted by Nevada Governor Sisolak and the Nevada State Board of Dental Examiners.

    Expanded the scope of practice for dental professionals during the COVID-19 pandemic.

    Facilitated an opportunity for oral health messaging to be presented to the Interim Health Care Committee

    in 2020 during a specific oral health focused meeting.

    Co-author and co-presenter of AB223 in Nevada’s 80th Legislative Session.

    Author of state policy for Urgent Dental Issues Identified During Community Screening.

    Amended 2018 State Standing Order for Fluoride Varnish Application for Community Nurses.

    Author of Medicaid Dental Services Expansion for Diabetic Patients. Accepted by Assemblywoman Neal

    for bill sponsorship in Nevada’s 80th Legislative Session.

    Successfully petitioned the Nevada State Board of Dental Examiners for inclusion of SDF and ITR as part

    of the scope of practice for Public Health Endorsed Dental Hygienists.

    Author of Health Assessment before School Entrance Policy proposal.

    Project Lead on Medical Miles for Rural Smiles collaborative with the Division of Public and Behavioral

    Health and Southern Nevada Health District which included facilitating the creation of $80,000 state grant.

    Author of informational memorandum to Assemblywoman Joiner for 79th Legislative Session Assembly

    Bill 193, Community Water Fluoridation.

    CHIEF DENTAL ADVISOR for the Nevada Division of Health Care Financing and Policy

    Job duties include providing clinical review and expertise for Medicaid administration of dental benefits.

    Position highlights include:

    Created Nevada Action Network a teledentistry and virtual fluoride varnish application program with DBA,

    Liberty Dental Plan for school-age children enrolled in Medicaid that are unable to receive school-based

    services due to COVID-19.

    Created the pilot Emergency Department Redirect Program for Non-Traumatic Dental Conditions.

    Provide clinical oversight of dental benefits administrator, Liberty Dental Plan.

    Revised and rewrote Nevada Medicaid Chapter 1000-Dental.

    Revised and rewrote PT 22 CDT Codes.

    Revised and edited Request for Proposal of Dental Benefits Administrator for State of Nevada RFP# 3290.

    Revised and edited Request for Proposal of Dental Benefits Administrator for State of Nevada RFP# 3425.

    Public Book Page 4

  • Author of bill draft request, Increased Medicaid reimbursement rates for dental procedures in dental health

    professional shortage areas(DHPSA) and rural Nevada. Submitted to the Division of Health Care

    Financing and Policy 2019 Legislative budget.

    VISITING ASSISTANT PROFESSOR for the UNLV School of Dental Medicine

    From 2016 to current, position involves academic lectures, dental public health strategic planning, and data

    collection. From 2012 to 2016, this position was a dual clinical teaching and admissions and student affairs

    position. Job duties include writing university policy, investigating measures to streamline admissions

    functions, researching marketing techniques, presenting lectures to pre-dental applicants at conferences and at

    weekly interviews, providing clinical supervision in the student clinic, and teaching pre-clinical courses.

    Position highlights include:

    Created a funding opportunity to support the 2020 CODA accreditation application for the UNLV SDM

    Public Health Residency Program.

    Admissions Evaluator for UNLV SDM Pre-Dental Applicants (Cycle 2012-13, 13-14, 14-15, 15-16).

    Co-Chair for SDM Senior Awards Gala.

    Developer and coordinator of the UNLV DMD-MPH Fast Track program.

    Founder of the UNLV SDM Peer Mentoring Program.

    Supervisor for transition and launch of a Salesforce based application portal.

    NEW PROGRAM CREATOR AND IMPLEMENTER

    Co-author of AB223 in Nevada’s 80th Legislative Session.

    Co-Creator of Emergency Department Redirect Pilot Program for Non-Traumatic Dental Conditions Using

    Teladentistry.

    Director of Medical Miles for Rural Smiles (2018).

    Special Projects Manager for SDM Salesforce application (2015-2016).

    Creator and Implementer of UNLV DMD-Fast Track MPH Program.

    Director of SDM Peer Mentoring Program (2014-2016).

    LEADERSHIP

    Standard Setting Panelists for the American Dental Association, DLOSCE Standard Setting Panel, 2020.

    Clinical Director for Nevada Special Olympics, Special Smiles.

    State Oral Health Leadership Institute Cohort 2, Center for Health Care Strategies (2017-2018)-10 month

    leadership program for state oral health and Medicaid teams to build leadership skills and policy

    knowledge.

    Director of New Student Orientation Week.

    Editor for UNLV’s ADEA Official Guide to Dental Schools Submission (2012-2016).

    Chief Scientists for ProStem Solutions with Orthodontic Resident Dr. Happy Ghag. The company competed

    at the 2014 Donald W. Reynolds Governor’s Cup and 2014 Southern Nevada Business Plan Competition.

    SCHOLARLY WORK

    Ebersole, J.; Son. Y.; Cappelli, D.;Demopoulos, C.; Cappuro, A.; Pinto, A.; Chrzan B.; Kingsley, K.;

    Howard, K.; Clark, N.; Khlystov, A. Aldehydes/Carbonyls from E-cigarettes/Vaping: Potential Deleterious

    Effects. Journal of Dental Research, June 2019. JDR-19-0566.

    K. Izuora, A. Basu, A. Alver, A. Salaza, A. Capurro, C. Gewelber, C. Cross, S. Williams and J. Ebersole

    Determinants of Nutritional Status Among Patients with Diabetes and Their Impact on Health Outcomes.

    (Clinical study in progress).

    K. Izuora, A. Basu, A. Alver, A. Salaza, A. Capurro, C. Gewelber, C. Cross, S. Williams and J. Ebersole.

    Relationship Between Plasma CRP And Fibrinogen Measured Using Dried Blood Samples And Vascular

    Public Book Page 5

  • Complications In Type 2 Diabetes. Poster presentation at the American Diabetes Association 80th Scientific

    Sessions (virtual meeting). Diabetes 2020 June; Volume 69: Supplement 1, https://doi.org/10.2337/db20-

    505-P

    Farfel,E; Capurro, A. Describing the Anatomy of Deciduous Mandibular Central Incisors. (In progress)

    Demopolous,C; Capurro,A; Kuprienko, K; Farnoush, Michelle; Carreiro, C. Oral Public Health Perception

    and Role in Dental Education. (In progress)

    Capurro, A; Ditmyer, M; Karishen, A. Marketing of Higher Education: Implications for Dental Schools. (In

    progress)

    Capurro, A; White, J; Packham, J. Nevada Workforce Survey with an Emphasis on Dental Services for

    Patients with Special Healthcare Needs. (In progress).

    GRANTS AND PROPOSALS

    Awarded Nevada Department of Education $35,000 grant to assess oral health status of children in licensed

    childcare facilities in rural Nevada. (2020).

    HRSA 20-026 “Rural Health Network Development Planning Program to Increase Access to Care for

    Populations Living in Health Professional Shortage Areas in Nevada” ”—Co-author. Application submitted

    on behalf of PACE Coalition in Elko, Nevada.

    Created a collaborative state funding opportunity of $250,000 for UNLV SDM Special Care Dental Clinic

    in 2020.

    2020 American Dental Education Association Annual Session and Expo—Reviewer of oral health abstracts

    2019 American Public Health Association Annual Meeting and Expo—Reviewer of oral health abstracts

    2019 Mountain West CTR-IN proposal, “Determinants of Nutritional Status Among Patients with Diabetes

    and Their Impact on Health” accepted for submission of full application.

    2019 Dental Trade Alliance Foundation Grant proposal, “ Expectant Mother Rural Medicaid Dental Access

    Pilot” accepted for submission of full application.

    HRSA 19-031 “Ryan White HIV/AIDS Program Part C Capacity Development Program” —Contributor.

    Application submitted on behalf of the Southern Nevada Health District.

    HRSA 19-025 “Rural Health Network Development Planning Program”—Co-author. Application

    submitted on behalf of William Bee Ririe Hospital in Ely, Nevada.

    CDC-RFA-18-1810 “State Actions to Improve Oral Health Outcomes” — Principal Investigator (PI).

    Application submitted on behalf of Nevada Oral Health Program.

    HRSA 18-014 “Grants to States to Support Oral Health Workforce Activities” —Principal Investigator (PI).

    Application submitted on behalf of Nevada Oral Health Program.

    Brokered a research relationship between the Division of Health Care Financing and Policy and Dr. Greg

    Oppenhuizen of the American Association of Orthodontists (AAO) in conjunction with the Angle Society-

    Midwest and the University of Detroit/Mercy for Nevada to be a part of a research study that may solidify

    or alter the AAO Committee on Medically Necessary Orthodontic Care’s decision.

    2018 Dental Trade Alliance Foundation Grant proposal, “Medical-Dental Integration within a Ryan White

    Clinic” accepted.

    2018 American Dental Education Association poster presentation—“Peer Mentoring” poster presentation

    accepted.

    Created a grant opportunity and facilitated delivery of $50,000 grant to UNLV SDM Special Care Dental

    Clinic in 2017.

    2017 Nevada Public Health Association Conference presentation —“Developmental and Intellectual

    Disabilities in Nevada with an Emphasis on Oral Health”.

    2017 American Association of Public Health Dentistry proposal, “Pilot Project to Improve Dental Access

    for Immunocompromised Adults with an Emphasis on Expectant Mothers” submitted.

    Public Book Page 6

  • State Oral Health Leadership Grant submitted to the Centers for Health Care Strategies. Application

    accepted in 2016. Oversaw successful completion of grant objectives.

    HRSA 17-068 (Predoctoral Pediatric Training in General Dentistry and Dental Hygiene) —Co-author.

    Proposal submitted by UNLV School of Dental Medicine.

    ADEAGies Foundation request for support for Fixed Dental Prosthesis Project 2015—Co-author

    Dental Anatomy Casebook for Thieme Publishers 06/2016—Reviewer

    MEDIA 2020—Legislative Committee on Health Care 2020—Plan for Dental Providers Offers Guidance for Procedures 2020—Nevada Independent, Facing lack of protective gear, dental hygienists want more guidance 2020—KTVN, Dentist during the Pandemic

    2019—Face the State Interview Part 1

    2019—Face the State Interview Part 2 2019—American Dental Association’s 2018, 10 Under 10 Award, New Dentists Blog 2019—American Dental Association’s 2018, 10 Under 10 Award, Member Center 2019—American Dental Association’s 2018, 10 Under 10 Award, Publication 2019—American Dental Association’s 2018, 10 Under 10 Award, New Dentists News 2019—Nevada Week S2, Ep 29: Healthcare in Rural Nevada 2018—Immunization and Oral Health Video with the Southern Nevada Health District 2018—Local Pahrump News, MM4RS 2018—Southern Nevada Health District Presentation 2018—Medical Miles for Rural Smiles Presentation 2018—Presentation to White Pine County Board of Public Health 2018—Presentation to Nye County Board of County Commissioners 2018—Presentation to Esmeralda County Board of Commissioners 2017—Nevada Public Health Association, Access to Care for Adults with Special Healthcare Needs 2017—International Academy for Dental-Facial Esthetics 2017—Nevada Dental Hygiene Association, Nevada Oral Health Legislative Day Report 2017 2017—Health Plan of Nevada Announcement 2017—Centers for Health Care Strategies, State Oral Health Leadership Institute Selection 2016—Nevada State Dental Health Officer Announcement 2016—Southern Nevada Business Plan Competition

    2013—11th Annual UC Davis Pre-Health & Pre-Medical National Conference, Building a Competitive

    Application Presentation

    CONFERENCE PRESENTATIONS

    • 2020 American Public Health Association 2020 Annual Meeting and Expo,Virtual Conference

    Emergency room redirect for non-traumatic dental conditions pilot project in Nevada using

    teladentistry

    Medicaid dental benefits evolve to tackle chronic health conditions in Nevada: A case study

    • 2020 National Oral Health Conference, Roundtable Session

    Emergency Room Redirect Pilot Using Teledentistry

    • 2020 Special Olympics, Special Smiles Virtual Summer Games

    Presenter, What Are Cavities

    Presenter, New Office Procedures

    • 2020 Southern Nevada Dental Society Dinner Meeting

    Presenter, Making Waves in the Desert

    • 2019 Nevada Health Conference

    Presenter, Emergency Room Redirect Pilot Using Teladentistry

    Public Book Page 7

  • Presenter, Medicaid Dental Benefits Evolve to Tackle Chronic Health Conditions in Nevada through AB223

    • 2019 Nevada Public Health Association Annual Conference

    Presenter, Medicaid Dental Benefits Evolve to Tackle Chronic Health Conditions in Nevada through AB223

    • 2018 Nevada Health Conference

    Presenter, Medical Miles for Rural Smiles, Oral Cancer, and HPV

    • 2018 Nevada Public Health Association Annual Conference

    Presenter, Medical Miles for Rural Smiles

    • 2017 Nevada Public Health Association Annual Conference

    Presenter, Developmental and Intellectual Disabilities in Nevada with an Emphasis on Oral Health

    • 2017 Nevada Dental Association Legislative Day

    Speaker, Oral Health in Nevada

    • 2017 Nevada Hygiene Association Legislative Day Speaker, Oral Health in Nevada

    • 2016 Nevada Dental Hygienist Association Annual Meeting Speaker, Nevada Oral Health Program-Today and Tomorrow

    • 2016 Nevada Public Health Association 2016 Annual Conference UNLV SDM Representative and Manager of Recruitment Booth

    • 2016 ADEA Annual Session “Shaping Tomorrow, Together” Student Poster Judge at the 2016 ADEA Annual Session UNLV SDM Representative for the ADEA Recruitment Fair

    • 2013 11th Annual UC Davis Pre-Medical and Pre-Health Professions National Conference Building a Competitive Application

    ACADEMIC GUEST LECTURER

    DEN # Title Semester/ year /hours per wk

    Den 7255 Overview of the Nevada Oral Health Program Summer/2020/1hr

    Successes, Challenges, and Policy Options

    Den 7354 State Perspective of Dental Services Summer/2020/1hr

    For Individuals with Intellectual and

    Developmental Disabilities (ID/DD)

    TMCC 2nd Year Course Dental Public Health in Nevada Fall/2019/ 1hr

    Den 7255 Dental Public Health in Nevada Spring/ 2019/1hr

    Den 7241/7242 Alloys, Ceramics, & Colors for Fixed Summer/2012/1hr

    Prosthodontics

    Den 7241/7242 Interim-Direct and Indirect Fabrication Summer/2012/1hr

    INTERNSHIP PRECEPTOR

    Letti Hale, Master of Public Health Internship, Spring 2020. Project focuses on workforce development for

    dentists and dental hygienists. Findings will inform a licensure survey for state data collection.

    Marcin Chimel, Master of Public Health Internship, Fall 2018. Project focuses on water fluoridation and

    dental caries throughout Nevada. Findings will be presented to the Advisory Committee on the State

    Program for Oral Health (AC4OH).

    Heidi Iongi, Doctor of Dental Medicine-Master of Public Health Fast Track Internship, Spring 2018.

    Designed a survey that reviewed the health assessment before school entrance policies of eighteen other

    states. Findings were presented to the Advisory Committee on the State Program for Oral Health (AC4OH)

    in September of 2018.

    Cathie Carrerio, Master of Education Internship, Fall 2017. Project focused on analyzing the differences in

    oral health modules provided to employees of Women, Infants, and Children(WIC) programs across the

    country and providing recommendations to Nevada’s WIC program.

    Public Book Page 8

  • PUBLIC HEALTH GOVERNANCE

    • 2019-2022 Commission on Autism Spectrum Disorder for the State of Nevada.

    Co-Chair and voting member of the Commission. Appointed by Governor Sisolak to provide leadership,

    oversight, and legislative advocacy in support of Nevadans living with Autism Spectrum Disorder.

    • 2019-2022 Nevada Dental Association, Council on Advocacy for Access and Prevention

    Chair and voting member of the Council which recommends policies, conducts activities, and builds

    interdisciplinary relationships to improve access to care and patient health outcomes.

    • 2019-2020 Maternal Child Health Steering Committee for the Statewide Maternal and Child Health

    Coalition

    Voting member of the steering committee to provide oversight and input in outreach, advocacy, and

    education for the maternal and child health population in Nevada.

    • 2019 Nevada Public Health Association Planning Committee

    Current committee member to plan the Nevada Public Health Association Annual Conference.

    • 2018-2020 Nevada Health Centers Board Member

    Current Board Secretary and voting member of Nevada Health Centers Board. Provide recommendations

    and strategies on the direction and strategies of the organization, assist leadership team in meeting HRSA

    grant objectives, and uphold the mission and values of the organization to provide quality care to Nevada’s

    most vulnerable populations.

    • 2018-2020 American Fluoridation Society’s Community Water Fluoridation Training Corps

    Voting member of American Fluoridation Society’s Community Water Fluoridation Training Corps.

    Members include local and state officials and oral health stakeholders from across the state. Through a

    grant from Delta Dental of California foundation, Nevada was chosen as one of four states to receive

    fluoridation training and technical assistance from the American Fluoridation Society.

    • 2018-2020 Families for Effective Autism Treatment (FEAT) of Southern Nevada Board Member

    Voting member of FEAT Board. Provide leadership and grant writing support for organization.

    • 2016-2020 Advisory Committee on the State Program for Oral Health

    Nonvoting ex officio member. Lead discuss on oral health initiatives in the state and provide

    information on current public health dental topics and progress of the State Oral Health Program. The

    purpose of the Committee is to support the state program and facilitate the delivery of oral health services.

    • 2017-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) Steering Committee

    Voting member of the PRAMS Steering Committee tasked with guiding recommendations for

    developing or modifying intervention programs or securing resources for program changes to reach

    mothers, children, and families in Nevada.

    • 2017-2020 ASTDD Dental Public Health Resources Committee

    Voting member of ASTDD Dental Public Health Resources Committee which develops and adopts a

    variety of documents including white papers, issue briefs and other dental public health resources

    statements to reflect the Association's priorities and stance on dental public health issues

    Public Book Page 9

  • • 2017-2018 Nevada Public Health Association

    Member-at-Large for the Nevada Public Health Association’s Southern Nevada Chapter. The Nevada

    Public Health Association provides public health professionals the opportunity to advocate for and

    contribute to public health policy and leadership development.

    • 2016-2018 Patient-Centered Medical Homes

    Voting member of the subcommittee for the Advisory Council on the State Program for Wellness and

    the Prevention of Chronic Disease.

    UNLV CAMPUS COMMITTEES

    • 2012-2016 Academic Faculty Senate Voting member of Academic Standards Committee on main campus which allows me to become even more

    familiar with University policies and standards as well as network with faculty from across campus.

    • 2016 UNLV Admissions Committee Voting member of Admissions Committee on main campus which allows me to become familiar with

    University undergraduate admissions policies and standards.

    • 2013-2014 UNLV Special Hearing Committee Panel Member| Voting member of the Special Hearing Committee which investigates and evaluates accusations of

    misconduct and recommends sanction.

    • 2013-2014 Faculty Senate Review Committee Member of the Faculty Senate Program Review Committee responsible for reviewing the Department of

    Theatre in the College of Fine Arts and submitting a written report of each undergraduate and graduate

    program within that department which will be sent to the Provost upon completion.

    UNLV SCHOOL OF DENTAL MEDICINE CAMPUS COMMITTEES

    • 2017-2020 Research Committee Voting member of committee which was created to facilitate research activities and review and provide

    feedback on research activities, issues, proposals, and potential funding opportunities within the SDM Office

    of Research. The committee develops a strategic plan for research efforts and recommends to the Dean

    allocation of research funds which have been placed at the Dean’s disposal.

    • 2016-2020 SDM Alumni Board Member-Board Secretary Voting member of UNLV SDM Alumni Board. The mission of the committee is to develop general

    activities, programs and resources relevant to supporting the mission of UNLV SDM.

    • 2014-2017 Dental Public Health Residency Committee Member Voting member of committee building the first DPH Residency program in Nevada. A member of the

    accreditation subcommittee to develop a CODA Self Study/Assessment document, review CODA Self

    Study/Assessment document, meet with consultants, participate in site visit, and annually evaluate DPH

    residency.

    • 2012-2017 SDM Admissions Committee Nonvoting ex officio member, I sit on the admissions committee and am aware of the procedures, rational

    and decisions being made.

    • 2015-2016 SDM Faculty Council Member; 2017-2018 SDM Faculty Council Secretary Alternate councilor representing the clinical sciences department. Forum serves to address faculty concerns

    Public Book Page 10

  • and communicate administrative initiatives.

    • 2013-2016 SDM Senior Gala Awards Committee Member Voting member of the Senior Gala Awards Committee. Faculty nominations for senior award recipients are

    submitted to committee, voted upon, organized and associated organizations notified.

    MEMBERSHIP IN PROFESSIONAL/SCIENTIFIC SOCIETIES

    Association of State and Territorial Dental Directors

    American Dental Association

    American Association of Public Health Dentistry

    American Dental Educational Association

    Beta Gamma Sigma Business Honor Society

    International Association of Coroners and Medical Examiners

    International Academy for Dental-Facial Esthetics

    Phi Kappa Phi Honor Society

    Medicaid-CHIP State Dental Association

    Nevada Public Health Association

    STUDY CLUBS

    UNLV SDM Research Club

    MAJOR TEACHING RESPONSIBILITIES

    DOCTORAL EDUCATION

    COURSE DIRECTOR

    DEN # Title Semester/ year /hours per wk

    7241 Simulated Comprehensive Care

    Lecture Summer/2016/1hr

    7242 Simulated Comprehensive Care

    Laboratory Summer /2016/3hr

    7233 Complete Denture Prosthodontics,

    Lecture and Laboratory Fall/2015/4hr

    7241 Simulated Comprehensive Care

    Lecture Summer/2015/1hr

    7242 Simulated Comprehensive Care

    Laboratory Summer /2015/3hr

    7233 Complete Denture Prosthodontics,

    Lecture and Laboratory Fall/2014/4hr

    7241 Simulated Comprehensive Care

    Lecture Summer/2014/1hr

    7242 Simulated Comprehensive Care

    Laboratory Summer /2014/3hr

    7233 Complete Denture Prosthodontics,

    Lecture and Laboratory Fall/2013/4hr

    7241 Simulated Comprehensive Care

    Lecture Summer/2013/1hr

    7242 Simulated Comprehensive Care

    Laboratory Summer /2013/3hr

    7233 Complete Denture Prosthodontics,

    Lecture and Laboratory Fall/2012/4hr

    UNDERGRADUATE COURSE LECTURER

    SCI 111 A Preview to Dentistry Spring/2014/1hr

    SCI 111 A Preview to Dentistry Spring/2013/1hr

    Public Book Page 11

  • SCI 111 A Preview to Dentistry Spring/2012/1hr

    PRE-CLINICAL INSTRUCTOR

    DEN # Title Semester/ year/ hours per wk

    7140 General Clinic Stream Class Summer /2015/ 4hrs

    7140 General Clinic Stream Class Spring /2015/ 4hrs

    7122 Applied Clinical Dentistry Summer /2014/ 1hr

    7137 Applied Clinical Dentistry Lab Summer/ 2014/ 3hrs

    7138 Preclinical Dentistry and Lab Summer/ 2014/ 4hrs

    7121 Principles of Clinical Dentistry Spring/ 2014/ 1hr

    7133 Principles of Clinical Dentistry Lab Spring/ 2014/ 3hrs

    7136 Basics of Periodontal Instrumentation Spring /2014/ 4hrs

    and Preventive Intervention

    7233 Complete Denture Prosthodontics and Lab Spring/2014/ 4hrs

    7124 Dental Anatomy and Occlusion Lab Fall/ 2013/ 3hrs

    7125 Dental Anatomy and Occlusion Fall/ 2013/ 1hr

    7140 General Clinic Stream Class Fall /2013/ 4hrs

    7122 Applied Clinical Dentistry Summer/ 2013/ 1hr

    7137 Applied Clinical Dentistry Lab Summer /2013/ 3hrs

    7138 Preclinical Dentistry and Lab Summer /2013/ 4hrs

    7139 Clinical Occlusion and Lab Summer/ 2013/ 4hrs

    7121 Principles of Clinical Dentistry Spring/ 2013/ 1hr

    7133 Principles of Clinical Dentistry Lab Spring /2013/ 3hrs

    7136 Basics of Periodontal Instrumentation Spring/ 2013/ 4hrs

    and Preventive Intervention

    7220 Principles of Endodontics Spring /2013/ 1hr

    7223 Principles of Endodontics Lab Spring /2013/ 3hrs

    7233 Complete Denture Prosthodontics and Lab Spring /2013/ 4hrs

    7125 Dental Anatomy and Occlusion Fall /2012/ 1hr

    7124 Dental Anatomy and Occlusion Lab Fall /2012/ 3hrs

    7140 General Clinic Stream Class Fall /2012/ 4hrs

    7241 Simulate Comprehensive Care Fall/ 2012/ 1hr

    7242 Simulated Comprehensive Care Lab Fall /2012/ 3hrs

    7122 Applied Clinical Dentistry Summer /2012/ 1hr

    7137 Applied Clinical Dentistry Lab Summer /2012/ 3hrs

    7138 Preclinical Dentistry and Lab Summer/ 2012/ 4hrs

    7139 Clinical Occlusion and Lab Summer /2012/ 4hrs

    7140 General Clinic Stream Class Summer/ 2012/ 4hrs

    7230 Orthodontics and Lab Summer /2012/ 4hrs

    7241 Simulate Comprehensive Care Summer/ 2012/ 1hr

    7242 Simulated Comprehensive Care Lab Summer /2012/ 3hrs

    7121 Principles of Clinical Dentistry Spring /2012/ 1hr

    7133 Principles of Clinical Dentistry Lab Spring /2012/ 3hrs

    7136 Basics of Periodontal Instrumentation Spring /2012/ 4hrs

    and Preventive Intervention

    7140 General Clinic Stream Class Spring /2012/ 4hrs

    7220 Principles of Endodontics Spring/ 2012/ 1hr

    7223 Principles of Endodontics Lab Spring/ 2012/ 3hrs

    7233 Complete Denture Prosthodontics and Lab Spring /2012/ 4hrs

    7241 Simulate Comprehensive Care Spring /2012/ 1hr

    7242 Simulated Comprehensive Care Lab Spring /2012/ 3hrs

    7124 Dental Anatomy and Occlusion Lab Fall /2011/ 3hrs

    7125 Dental Anatomy and Occlusion Fall/ 2011/ 1hr

    7140 General Clinic Stream Class Fall /2011/ 4hrs

    Public Book Page 12

  • 7241 Simulate Comprehensive Care Fall /2011/ 1hr

    7242 Simulated Comprehensive Care Lab Fall /2011/ 3hr

    7122 Applied Clinical Dentistry Summer /2011/ 1hr

    7137 Applied Clinical Dentistry Lab Summer /2011/ 3hrs

    7139 Clinical Occlusion and Lab Summer /2011/ 4hrs

    7140 General Clinic Stream Class Summer/ 2011/ 4hrs

    CLINICAL INSTRUCTOR

    DEN # Title Semester/year /hours per wk

    7340/7440 Screening Clinic Summer /2016/8 hrs

    7140 General Clinic Stream Class DS1 Summer/ 2016/4 hrs

    7340/7440 Screening Clinic Spring /2016/8 hrs

    7140 General Clinic Stream Class DS1 Spring/ 2016/4 hrs

    7340/7440 Screening Clinic Fall /2015/8 hrs

    7140 General Clinic Stream Class DS1 Summer/ 2015/4 hrs

    7340/7440 Screening Clinic Summer /2015/8 hrs

    7340/7440 Screening Clinic Spring /2015/8 hrs

    7140 General Clinic Stream Class DS1 Spring/ 2015/4 hrs

    7340/7440 Denture Clinic Fall /2014/4 hrs

    7140 General Clinic Stream Class DS1 Summer/ 2014/4 hrs

    7140 General Clinic Stream Class Team 3 Spring/ 2014/4 hrs

    7140 General Clinic Stream Class Team 1 Fall/ 2013/4 hrs

    COURSE MATERIALS DEVELOPED

    2013 DEN 7241 PowerPoint presentations for Simulated Comprehensive Care Class

    2013 DEN 7242 Grading Criteria for evaluation of the student’s work

    2013 DEN 7233 PowerPoint presentations and grading criteria development

    2012 DEN 7241 PowerPoint presentations for Simulated Comprehensive Care Class

    2012 DEN 7242 Grading Criteria for evaluation of the student’s work

    2012 DEN 7233 PowerPoint presentations and grading criteria development

    Public Book Page 13

  • Agenda Item (4)(a)Public Health Dental Hygiene and

    Dental Therapy Subcommittee Member: Robert Talley, DDS

    Public Book Page 14

  • Public Book Page 15

  • NEVADA DENTAL ASSOCIATION INSURANCE AGENCY BOARD MEMBER 1995-2006 STATE OF NEVADA

    ADVISORY COMMITTEE ON THE STATE PROGRAM FOR ORAL HEALTH 2010- 2020

    ROSEMAN UNIVERSITY BOARD OF TRUSTEES 2008-PRESENT

    UNLV SCHOOL OF DENTAL MEDICINE

    DEAN SEARCH COMMITTEE STANDARDS OF CARE COMMITTEE LIASON TO NEVADA DENTAL ASSOCIATION 2004-2006

    CURRICULUM REVIEW COMMITTEE DEAN’S ADVISORY COMMITTEE 2005-2006 DENTAL SCHOOL ADVISORY COMMITTEE- 2012-2020

    AMERICAN DENTAL ASSOCIATION ALTERNATE DELEGATE 1998-2000 DELEGATE-SOUTHERN NEVADA 2002- 2005 COUNCIL ON DENTAL PRACTICE 2002- 2006 TRUSTEE- NATIONAL BOARD OF CERTIFICATION 2005- 2007 NATIONAL ASSOCIATION OF DENTAL LABS ADA/KELLOGG INSTITUE MANANGEMENT PROGRAM 2005 HONORS FELLOW- PIERRE FAUCHARD ACADEMY ACADEMY OF DENTISTRY INTERNATIONAL AMERICAN COLLEGE OF DENTISTRY

    RECEIVED THE INAGURAL UNLV/SNDS COMMUNITY SERVICE AWARD 2017

    COMMUNITY SERVICE SOUTHWEST ROTARY CLUB 1982-88 MEMBER- CENTRAL CHRISTIAN CHURCH 1981-2017 SIN CITY CHRISTIAN CHURCH- 2017-PRESENT

    Public Book Page 16

  • HOBBIES GOLF, HUNTING, FISHING

    Public Book Page 17

  • Agenda Item (4)(a)Public Health Dental Hygiene and

    Dental Therapy Subcommittee Member: Lancette VanGuilder, RDH

    Public Book Page 18

  • November 6, 2020

    To: Nevada State Board of Dental Examiners From: Lancette VanGuilder, RDH, BS

    RE: NSDBE Board Meeting on November 10, 2020

    Dental Hygiene and Dental Therapy Subcommittee

    Cover Letter for Board Agenda item 7(f), CV sent to Mr. Su

    I am extremely honored and excited to be considered to serve on the Subcommittee for Dental Hygiene and Dental

    Therapy. At the recent committee meeting, the chair requested documentation that supports appointees based on

    merit and knowledge on the subject of dental therapy. I am excited that committee appointments will be based

    on content knowledge and expertise and wanted to share my background with you.

    • I have over 11 years of active working knowledge in the area of dental therapy/ midlevel

    providers/alternative workforce models, from 2009 to present day. This includes international and United

    States based data collection and perspective.

    • I drafted the language and worked with the LCB for SB366 that was presented to the Nevada Legislature

    in 2019, including amendments and final bill language that now exists in Nevada Statute. I would consider

    myself a content expert who worked with the bill sponsor (Senator Ratti) on a weekly basis for 6 months

    and have a very clear picture of the legislative intent of the bill. I worked extensively with nearly a dozen

    of the bill supporters (Nevada Tribes, Primary Care Associations, Public Health Associations, Nevada

    Community Based Non-Profits, Insurance Companies, Nevada Dental Hygienists Association) as well as the

    only group that had initial opposition but went on record as neutral on SB366 (Nevada Dental

    Association).

    • I am a professional continuing education speaker and have been presenting continuing education courses

    around the nation to dentists and dental hygienists on dental therapy for the last 5 years; including the

    background, the education and the various models.

    • I have served on local, state and national boards/committees for the entirety of my 25 years in the dental

    hygiene profession and have solid knowledge of parliamentary procedure and Robert’s Rules of Order.

    • I currently serve on the City of Sparks Charter Committee. This committee presents language to the

    Nevada Legislature regarding the City of Sparks.

    • I currently serve as the chair of the Nevada Dental Hygienists Association Legislative Committee. My

    duties are to adhere to the mission of the NDHA: To improve the public’s total health, to advance the

    art and science of dental hygiene by ensuring access to quality oral health care, increasing

    awareness of the cost-effective benefits of prevention, promoting the highest standards of dental

    hygiene education, licensure, practice, and research, and representing and promoting the

    interests of dental hygienists.

    I do think that if the committee members could already be well versed on the bill language/intent and if the

    subcommittee could be comprised of members with expertise in dental therapy background, it would help the

    meetings proceed in an efficient manner. I am optimistic that the goal of the meetings could be to: 1) to increase

    access to dental care with regulatory language that would allow for dental therapy implementation in our state

    that enables providers to utilize their full scope of education and practice and 2) protect the public.

    Thank you, in advance, for your consideration and I apologize that I cannot attend meetings held on Tuesdays due

    to my work schedule.

    Lancette VanGuilder, RDH, BS

    Public Book Page 19

  • LANCETTE VANGUILDER, BS, RDH

    Curriculum Vitae

    EDUCATION

    University of Nevada, Reno

    Certificate in Non-Profit Management March 2018

    High Sierra Health Education Council (AHEC), Reno, Nevada

    Professional Development: HPV Educator March 2017

    O’Hehir University

    Bachelor of Science, Oral Health Promotion March 2017

    University of South Dakota, Vermillion, South Dakota 1993-1995

    Associate of Science, Dental Hygiene

    Certificate in Local Anesthesia and Nitrous Oxide

    Truckee Meadows Community College, Reno, Nevada 1990-1991

    Associate of Applied Science, Dental Assisting

    University of Nevada, Reno 1989-1991

    General Studies

    White Pine High School 1986-1989

    General studies, graduated High school diploma

    AWARDS

    National

    Irene Newman Professional Achievement Award, American Dental Hygienists Association 2018

    *Highest honor to recognize the advancement of the art and science of the dental hygiene profession over the last 15 years

    Inducted to Sigma Phi Alpha National Dental Hygiene Honor Society 2008

    Regional

    Community Service Finalist, Triumphant Celebrating Women in Leadership 2018

    State

    Innovative Career Vision Award, Nevada Dental Hygienists Association 2017

    “Nevada Dental Hygienist of the Year”, Nevada Dental Hygienists Association 2011

    Public Book Page 20

  • PROFESSIONAL EXPERIENCE Hygienist for Health 2020-present

    Founder/owner AGD PACE Approved Continuing Education Company; focus on multi-disciplinary care and education

    Community Dental Connections 2018-present Founder/owner- Public Health Endorsed Mobile Dental Hygiene Program

    Unpaid Registered State Lobbyist (Nevada)- Dental Therapy and SB366 2017-2019

    Sierra Smiles-Zephyr Cove, Nevada 2016-present

    Registered Dental Hygienist-Lead

    Areas of expertise: Complete Health Practice, Periodontics, CO2 and Diode laser, perio protect, salivary diagnostics, risk assessments, airway assessments, patient education, delivery of preventive and therapeutic services.

    WaterPik, Inc. 2016-present

    Professional Educator

    Provide in- office lunch and learn educational presentations

    Future Smiles of Northern Nevada 2016-2019

    Public Health Dental Hygienist, Program Manager

    Nonprofit, school based dental hygiene program: provide oral health supplies and education to students,

    collect oral health data and place fluoride varnish and dental sealants. Facilitated case management.

    Assisted with program development and grant writing, collaborative partnerships with coalition and

    school districts. Program served 10,000 students, from age 4 to 20.

    International Continuing Education Speaker (*see courses below) 2015-present National and Regional CE meetings, Study Clubs, University Based, Corporate Development, Professional

    Associations, Nonprofits, current average: 9,600 attendees per year. *courses available upon request Provide clinical education (lecture and hands-on) to dentists, hygienists, dental therapists and assistants

    American Dental Hygienists Association-Chicago, IL 2012-202016

    Board of Trustees-District XII Trustee

    Representing: Washington, Oregon, Nevada, Idaho, Alaska and Hawaii

    Tony DePaoli, DDS and Sorren McCool, DDS-Sparks, NV

    Registered Dental Hygienist-family practice 2003-2016

    Area of Expertise-Periodontics, prevention

    Steve Robinson, DDS-Reno, NV

    Registered Dental Hygienist 2001-2003

    Periodontics, Perioscopy

    Public Book Page 21

  • CD Jackson-Miller, DDS-Fernley, NV 1998-2001 Registered Dental Hygienist Implemented dental hygiene department, policies and protocol

    Registered Dental Hygienist, family practice

    Maurice Palermo, DDS-Reno, NV

    Dental Assistant

    1991-1993

    TEACHING EXPERIENCE

    Truckee Meadows Community College-Reno, NV 2002-2005, 2016-2019

    Dental Hygiene Site Instructor, Future Smiles of Northern Nevada 2016-2019

    Dental Hygiene Adjunct Instructor 2002-2005

    Periodontics III, Local Anesthesia/ Nitrous Oxide, Dental materials lab

    Didactic and Lab teaching

    Second year Dental Hygiene Clinic

    Instructor Dental Hygiene Site Instructor

    VA Medical Center, Indian Health Service LEADERSHIP EXPERIENCE

    American Dental Hygienists’ Association (ADHA) Board of Trustees 2011-2016

    District XII Trustee: Represent Washington, Oregon, Nevada,

    Idaho Alaska and Hawaii

    Strategic planning, budget development, bill drafts and

    lobbying, Leadership development/training, best practices,

    public relations/ Communications and House of Delegates,

    Advocacy Training

    ADHA National Appointments: ADHA Leadership Development Committee

    ADHA Finance Committee

    2017-2018 2013-2016 ADHA Board Advisor for the Council on Regulation and Practice 2014-2015

    ADHA Board Advisor for the Council on Research 2011-2013

    ADHA Council on Member Services 2011-2013, 2015-2016

    ADHA Council on Public Relations 2009-2011

    ADHA Delegate for Nevada 2006-2011

    ADHA Committees: Annual Session, student relations, Scholarships 2005-2011

    ADHA Institute for Oral Health: donor 1995-present

    Nevada Dental Hygienists’ Association President

    2005-2008

    President-Elect 2004-2005

    Public Book Page 22

  • Legislative Chair, Legislative Committee 2004-2011, current

    NDHA PAC Chair 2004-Present

    Committees: Annual Session, policy and bylaws, Scholarship, meeting planning

    2004-2011

    Northern Nevada Dental Hygienists’ Association

    Vice President, Treasurer, Newsletter editor, Speaker of the House, President- Elect

    1998-2004,2016

    South Dakota Dental Hygienists Association 1996-1998

    Vice President of Black Hills Component

    Student American Dental Hygienists Association, Vice President 1994-1995

    CERTIFICATIONS

    Soft Tissue Laser-World Clinical Laser Institute, ALD 2016

    Local Anesthesia-University of South Dakota 1995

    Nitrous Oxide-University of South Dakota 1995

    NATIONAL PUBLIC SPEAKING: Leadership/Strategic Planning, Advocacy ADHA Unleashing Your Potential Workshop, Chicago, IL 2017 Oregon Dental Hygienists Association 2013,2015

    Alaska Dental Hygienists’ Association 2012, 2013, 2014

    University of Alaska, Anchorage 2012,2013, 2014

    Washington State Dental Hygienists’ Association 2012, 2013, 2014, 2015

    Washington State Student Dental Hygienists’ Association 2013

    Idaho Dental Hygienists’ Association 2013, 2014, 2015

    Hawaii Dental Hygienists’ Association 2012,2013,2014-2016

    University of Hawaii, Manoa (students and faculty) 2015

    Nevada Dental Hygienists’ Association 2012,2013,2014-2016

    College of Southern Nevada-Las Vegas, NV 2015

    Truckee Meadows Community College -Reno, NV 2013

    ADHA Leadership Panel: Annual Session/CLL and Leadership workshop

    2015, 2011 & 2013

    Public Book Page 23

  • RELATED WORK EXPERIENCE

    Public Speaking 2008-present

    Topics: product presentation, local anesthesia, leadership training, best practices and fiduciary responsibility,

    strategic planning, budget development and assessment, conflict resolution, communication styles,

    dental hygiene workforce/education trends and dental hygiene advocacy.

    Continuing education programs and leadership development.

    Technology

    Expert in multiple computer operating systems, Proficient in Prezi, PowerPoint, Excel and Word

    Conduct Web based meetings (Zoom, WebEx, GoToMeetings), skilled in email and social media, proficient in

    Dentrix and Eagle Soft, VSee and Turnitin. Intra and extra oral photography.

    Washoe County Coalition for the Underserved Populations, board member 2004-2006

    University of Nevada Workforce Research Team 2006

    Community Service-dental hygiene related 1998-present

    Nevada National guard readiness screenings, American Heart Association, Autism Coalition,

    health fairs, oral health screenings, Nevada Nurses Association, Nevada Diabetes

    Association, boy scouts, preschools, elementary schools, Lobby days

    PROFESSIONAL MEMBERSHIPS

    American Dental Hygienists Association 1995-present

    Nevada Dental Hygienists Association 1998-present

    Northern Nevada Dental Hygienists Association 1998-present

    Flying Doctors 2011-present

    Member of Sigma Phi Alpha Dental Hygiene Honor Society 2008-present

    South Dakota Dental Hygienists Association 1995-1998

    Student American Dental Hygienists Association 1995-1998

    Western Society of Periodontology 2000-2005

    Reno-Tahoe Dental Hygiene Study Club 2008-2011

    National Network of Healthcare Hygienists Jan. 2020-current

    National Mobile and Teledentistry Alliance Jan. 2020-current

    PROFESSIONAL LICENSURE

    Dental Hygiene license, Nevada (license 3227) 1998-present

    Nevada Public Health Endorsement 2016-2019, current

    Dental Hygiene Local Anesthesia and Nitrous Oxide, Nevada 1998

    Dental Hygiene Laser Endorsement, Nevada 2016-present

    Dental Hygiene license, South Dakota 1995-2010

    CPR and First Aid for Healthcare Providers 1990-present

    Public Book Page 24

  • Agenda Item (4)(a)Public Health Dental Hygiene and

    Dental Therapy Subcommittee Member: Jessica Woods, RDH

    Public Book Page 25

  • November 10, 2020 Dear Nevada State Board of Dental Examiners, Thank you for your consideration for appointment on the Dental Hygiene and Dental Therapy sub-committee. Here are a few highlights of my professional background that aid my work on the committee.

    • Served as President-Elect and a member of the Legislative Committee for the Nevada Dental Hygienist’ Association during the time that SB366 was being considered. Strong understanding of legislative processes and implementation.

    • Subject matter expert on oral health needs of rural communities within Nevada through data collection during the Medical Miles 4 Rural Smiles project (2018) and Silver State Smiles in Licensed Childcare Facilities (2020).

    • Have held a public health endorsement from NSBDE for the following programs: Future Smiles, Southern Nevada Health District, and Nevada Oral Health Program (pending).

    • Currently hold a license and have prior working experience as a Registered Dental Hygienist in Alternative Practice (RDHAP) [independent practice] in the state of California. Also, served on the California Dental Hygienists’ Association (CDHA) RDHAP Committee.

    • Vast working knowledge around alternative workforce models (collaborative agreements, midlevel providers, virtual dental home, school-based and rural health centers, etc.) and expanded scope of practice procedures for dental hygienists (intermediate therapeutic restorations, silver diamine fluoride, etc.).

    • High level of compassion and integrity when working with underserved populations. I am happy to expand on my professional background should you have additional questions. Again, I thank the Board for their consideration and look forward to upholding the mission of NSBDE; to protect the dental health interest of Nevadans. Sincerely. Jessica L. Woods, MPH, RDH

    Public Book Page 26

  • Public Book Page 27

  • Licensure & Certifications • Community Dental Health Coordinator (2018)

    • Public Health Endorsed Dental Hygienists (Nevada)(2017)

    • Registered Dental Hygienist (Nevada) (2017)

    • Registered Dental Hygienist in Alternative Practice (California): CA License HAP542 (2014)

    • Registered Dental Hygienist (California): CA License RDH25954 (2011)

    • Oral and Maxillofacial Surgery Assistant (2009)

    • Registered Dental Assistant (California): CA License RDA64252 (2005)

    • BLS Health Care Provider (Current)

    • Soft Tissue Diode Laser Certification (2012)

    • Western Regional Examination Board (WREB) (2013)

    Southern California Family Dentistry – Dental Hygienist 2013 – 2016

    • Established and implemented dental hygiene department protocols

    • Trained doctors and staff in soft tissue diode laser science and techniques

    • Evaluated and instructed employees on standards of infection control Inland Dental Group – Dental Hygienist 2014 – 2016

    • Coached co-worker on non-surgical periodontal therapy protocols and laser use

    • Handled scheduling conflicts as part of access to care development activities West Coast Dental Services – Dental Hygienist 2011 – 2014

    • Participated in management team presentation that successfully led to partnership with company valued at more than $139 billion

    West Coast Dental Services – Oral & Maxillofacial Surgery Assistant 2007 – 2011

    • Supported travelling surgical team, adapting to a wide variety of working environments

    • Assisted in surgical procedures, monitoring patient vitals and intravenous fluids as they were under conscious sedation Diamond Bar Periodontics – Dental Assistant 2009 – 2010

    • Assisted in advanced surgical periodontal procedures

    • Delivered written and oral surgical reports to referring dentists

    • Corresponded with patients regarding follow-up procedures City of Hope Medical Center – Nursing Unit Secretary 2005 – 2007

    • Transcribed physician orders and prepared daily lab and radiography requisitions Hanfu Lee DDS – Dental Assistant 2004 – 2006

    • Handled most traditional chairside and hygiene assistant duties John F. Mack, DDS – Dental Assistant 2002 – 2004

    • Developed real-world dental assisting training and application, while obtaining licensure

    Memberships & Recognition • Memberships with: ADHA, CDHA, OCDHS, NDHA,

    SNDHA (2010 – Present)

    • Student Delegate: Orange County Dental Hygiene Society (2009 – 2011)

    • Outstanding Student Service Award Recipient – College of Graduate Health Studies (2018)

    • American Dental Association Scholarship Recipient (2017 – 2018)

    • CDHA RDHAP Counsel (2016 – 2017)

    • Community Outreach Oral Health Educator: Human Options (2011)

    • Volunteer RDH: Modern House Call for Women (2010)

    • Volunteer RDA: Dentistry from the Heart – Park Place Dental (2010)

    • Lead Volunteer Coordinator: Students for Environmental Education and Discovery (2004 – 2007)

    • President: Student in Free Enterprise (2005 – 2006)

    Education A.T. Still University (Mesa, AZ) Master’s in public health 2018 Rio Salado College (Tempe, AZ) Community Dental Health Coordinator 2018 West Los Angeles College (Los Angeles, CA) Registered Dental Hygienist in Alternative Practice 2014 West Coast University (Anaheim, CA) BS, Dental Hygiene 2011 Azusa Pacific University (Azusa, CA) Applied Heath with Concentration in Business 2007 North-West College (West Covina, CA) Dental Assisting Certificate 2003

    Public Book Page 28

  • Agenda Item (4)(b)(1):

    Appointment to Public Health Dental Hygiene and Dental Therapy Subcommittee

    Steven Saxe, DMD

    Public Book Page 29

  • Public Book Page 30

  • 3. Washington University School of Dental MedicineHonors Program in Oral Surgery at Veterans AssociationMedical Center, St. Louis, Missouri and Scott Air Force

    Base in Bellville, Illinois4. Oral and Maxillofacial Surgery Division, Chairman and

    founder of the Southern Nevada Craniofacial and CleftPalate Team; Special Children’s Clinic established October1992, Las Vegas, Nevada

    5. Delegate to the Clark County dental Society.6. Oral and Maxillofacial Surgery Division Chairman,

    Columbia Sunrise Children’s Hospital7. General practice residency Founder & Program Director

    University of Nevada School of Medicine8. Clinical Assistant Professor Department of Surgery

    University of Nevada School of Medicine9. President of Nevada Division of the American Association

    of Oral and Maxillofacial Surgeons10. Alternate/ Delegate to AAOMS House of Delegates11. Department Chairman of Oral & Maxillofacial Surgery

    Mountain View Hospital Las Vegas, Nevada12. Department Chairman of Oral & Maxillofacial Surgery

    Sunrise Hospital and Sunrise Children’s Hospital LasVegas, Nevada

    13. Clinical Professor in Oral & Maxillofacial Surgery UNLVSchool of Dental Medicine

    14. Nevada Delegate to the American Dental Association

    15. Inspector and Evaluator of General Anesthesia NevadaState Board of Dental Examiners

    16. Treasurer Southern Nevada Dental Society

    Professional Affiliations:1. Fellow of the American Association of Oral and

    Maxillofacial Surgery

    2. Fellow of the American College of Oral and MaxillofacialSurgery

    Public Book Page 31

  • 3. Diplomat of the America Board of Oral and MaxillofacialSurgery

    4. American Dental Association

    5. Alpha Omega Dental Fraternity

    6. Southern Ontario Surgical Orthodontic Study Group

    7. Nevada Dental Association/Southern Nevada DentalSociety

    8. Member Chalmers J. Lyons Academy of Oral andMaxillofacial Surgery

    9. Dental Director and founder of University of NevadaSchool of Medicine General Practice Dental Residency

    10. Pierre Fauchard Academy

    11. Michigan dental Association

    12. Detroit Academy of Oral and Maxillofacial Surgeons

    13. Diplomat National Dental Board of Anesthesiology

    14. Fellow of the International College of Dentists

    Research Experience:

    1. Interpretation of Panoramic Radiographs to locate theposition of the Mandible Foramen.January 1984 to June 1984Dr. Ray Rawson, D.D.S.Las Vegas, Nevada

    2. Analysis of Analog EMG Data collected at the Museum ofComparative Zoology at Harvard.Computer Digitizing and Analysis of Spine x-ray filmscollected at the Museum of Comparative Zoology atHarvard. Full-time during the summer of 1985 and part-

    Public Book Page 32

  • time during academic year 1985-1986, in the Anatomy Labof Dr. R.Z. German, Ph.D., W.U.S.D.M.

    3. Interpretation and reviewing Orthoganathic surgery casefiles (May 1987). Dr. K.S. Rotskoff, D.M.D., St. Mary’sHospital Center of St. Louis, Missouri.

    Awards:1987 - Student Table Clinic Fourth Place (TemporomandibularJoint Arthroscopic Surgery)1986 - Student Table Clinic Fourth Place (Tongue Function andIntraoral Transport)1988 - Quintessence Award for Academic Achievement.1988 - American Academy or Oral Pathology, Oral PathologyAward1988 – Alpha Omega Undergraduate Scholarship Award Academic Publications:German, R.A., Saxe, S.A., Hiiemae, K.M., Crompton, A.W.Food Transport through the Anterior Oral Cavity inMacaques.American Journal of Physical Anthropology 1989 Nov: 80(3):369-77 Saxe, S.A., In Prep 1. Eosinophillic Granuloma a casereport

    2. 20 year Retrospective Study of Head andNeck Cancer at Sinai Hospital of Detroit

    Public Book Page 33

  • Agenda Item (4)(b)(4):

    Appointment to Public Health Dental Hygiene and Dental Therapy Subcommittee

    Kelly Taylor, RDH

    Public Book Page 34

  • Public Book Page 36

  • MISSION STATEMENT FOR DENTAL HYGIENE AND DENTAL THERAPY SUBCOMMITTEE

    The mission of the Public Health Dental Hygiene and Dental Therapy Subcommittee is to assist the Dental Hygiene and Dental Therapy Committee in developing guiding principles and policy goals for dental hygienists and dental therapists to increase access to oral health services to the citizens of Nevada, especially those in underserved populations; to improve oral health of the citizens of Nevada; to improve health equity and achieve greater diversity of the oral health workforce; to provide for safe, high quality oral health services; and to support safety net providers, such as federally qualified health centers, rural health clinics, tribal health clinics, and other entities that serve patients who are low-income and uninsured.

    Public Book Page 37

  • Agenda Item (d)(1):

    Administration of Vaccinations by Licensed Dental Professionals (NAC 631.2562)

    Public Book Page 38

  • IMMUNIZATION BY DENTAL PRACTITIONER

    NAC 631.009 “Dental Practitioner” defined. Dental practitioner means a dentist , dental hygienist, dental hygienist with a public health endorsement, or dental therapist who is licensed pursuant to Chapter 631 of NRS. A dental hygienist who holds an active license pursuant to this chapter must work under the direct and immediate supervision of a licensed Nevada dentist. A dental therapist who holds an active license pursuant to this chapter must work under a written agreement with an authorized dentist. NAC 631.0091 “Model Standing Orders” defined. Model standing orders means prewritten orders and specific instructions for administration and frequency of a given medication (vaccines) to a person in clearly defined circumstances by the Board and the Department of Health and Human Services. NAC 631.0092 “Vaccines for Children” (VFC) defined. Vaccines for children means a federal program that provides vaccine serums at no cost to providers for clients 0 to 18 years of age. NAC 631.0093 “Immunization” defined. As used in NAC 639.297 to 639.2978, inclusive, unless the context otherwise requires, “immunization” means the act of inducing antibody formation through the introduction of a drug into the human body. NAC 631.0094 “Vaccine Information Statement” (VIS) defined. Vaccine Information Statement (VIS) means vaccine information statement developed and maintained by the Centers for Disease Control and Prevention. Current versions can be found at: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html NAC 631.0095 “Immunization Information System” defined. Immunization Information System means the informational collection system administered by the State Board of Health and outlined in NRS 439.265.

    NAC 631.2561 Authorization; administration of vaccines 1. A person licensed to practice dentistry as outlined in Chapter 631 shall be deemed to be practicing dentistry while participating in

    the prescription and administration of vaccines. 2. A dental practitioner may administer immunizations by an intranasal, intramuscular or subcutaneous injection only:

    (a) To a patient of record; (b) If the dental practitioner has completed an immunization certification program approved by the Board; (c) If vaccines are administered in accordance with the “Model Standing Orders” approved by the Board and the Department of

    Health and Human Services. (d) If written policies and procedures for handling and disposal of used or contaminated equipment and supplies are maintained. (e) If the dental practitioner has immediate access to emergency response equipment, including but not limited to oxygen

    administration equipment, epinephrine, and other allergic reaction response equipment; (f) If the dental practitioner or designated staff has given the appropriate Vaccine Information Statement (VIS) to the patient or

    legal representative with each dose of vaccine covered by these forms. The dental practitioner must ensure that the patient or legal representative is available and has read, or has had read to them, the information provided and has had their questions answered prior to the dental practitioner administering the vaccine. The VIS given to the patient must be the most current statement.

    3. The dental practitioner or designated staff must document in the patient record: (a) The date and site of the administration of the vaccine; (b) The brand name, or national drug code (NDC) number, or other acceptable standardized vaccine code set, dose,

    manufacturer, lot number, and expiration date of the vaccine;

    Public Book Page 39

  • (c) The name or identifiable initials of the administering dental practitioner; (d) The address of the office where the vaccine(s) was administered unless automatically embedded in the electronic report

    provided to the Immunization Information System according to NRS 439.265; (e) The date of publication of the VIS; and (f) The date the VIS was provided and the date when the VIS was published.

    4. If providing state or federal vaccines, the vaccine eligibility code must be reported to the Immunization Information System. 5. A dental practitioner who administers any vaccine must report, the elements of Section (3), and Section (4) of this rule if applicable,

    to the Immunization Information System within 14 days of administration. 6. The dental practitioner must report adverse events to the Nevada State Board of Dental Examiners within 10 business days and to

    the primary care provider as identified by the patient. 7. A dental practitioner who administers any vaccine will follow storage and handling guidance from the vaccine manufacturer and

    the Centers for Disease Control and Prevention (CDC). 8. Any dental practitioner administering immunizations by an intranasal, intramuscular or subcutaneous injection under this section

    shall comply with guidelines established by the federal Advisory Committee on Immunization Practices (ACIP) relating to vaccines and immunizations, which includes, but is not limited to, vaccine storage and handling, vaccine administration and documentation, and vaccine contraindications and precautions.

    9. Non-compliance with all sections within NAC 631.2561 may be viewed as unprofessional conduct which is subject to disciplinary action by the Nevada State Board of Dental Examiners.

    NAC 631.2562 Training and certification to administer immunizations. 1. Before a dentist or dental hygienist with a public health endorsement may administer an immunization, or before a dental hygienist acting under the direct and immediate supervision of a dentist may administer an immunization, or before a dental therapist acting under a written agreement with an authorized dentist may administer an immunization, the dental practitioner must be trained and certified to administer immunizations by completing an immunization certification program approved by the Nevada State Board of Dental Examiners that includes: (a) Education and practical training, including, without limitation, written study materials regarding techniques for administering immunizations; (b) Evaluation of the knowledge and technique of the dental practitioner in administering immunizations; (c) Instruction consistent with the current training guidelines of the Centers for Disease Control and Prevention; and (d) Except as otherwise provided in subsection 2, instruction and practical training concerning: (1) The standards for pediatric, adolescent and adult immunization practices recommended and approved by the United States Public Health Service Advisory Committee on Immunization Practices; (2) Basic immunology, and vaccine and immunization protection; (3) Diseases that are preventable through vaccination and immunization; (4) Recommended immunization schedules; (5) Vaccine and immunization storage and management; (6) Informed consent; (7) Physiology and techniques for administration of immunizations; (8) Preimmunization and postimmunization assessment and counseling; (9) Immunization reporting and records management; and (10) Identification, response, documentation and reporting of adverse events.

    Public Book Page 40

  • 2. In lieu of complying with the requirements of paragraph (d) of subsection 1, a dental practitioner who administers immunizations consisting exclusively of live attenuated influenza vaccine through the nasal passages of a person may complete a certification program of instruction which is approved by the Nevada State Board of Dental Examiners and includes instruction relating to: (a) The epidemiology of influenza; (b) The pathophysiology, clinical presentation, diagnosis, prevention and treatment of influenza; (c) The administration, storage and handling of influenza vaccines; and (d) The counseling of patients who will be immunized with the vaccine. NAC 631.2563 Certification in basic cardiac life support; continuing education. A dentist or dental hygienist with a public health endorsement who administers immunizations, or a dental hygienist acting under the direct and immediate supervision of a dentist who administers immunizations, or a dental therapist acting under a written agreement with an authorized dentist to administer immunizations, shall: 1. Maintain certification in basic cardiac life support from the American Heart Association; and 2. On or before of each year, complete:

    (a) At least 2 hours of continuing education in a course or courses that address the life cycle of diseases, drugs and administration of immunizations; or

    (b) A course provided by the Centers for Disease Control and Prevention regarding epidemiology and prevention of diseases which are preventable through immunization; or

    (c) A training course offered by Immunize Nevada or its successor organization; or (d) Any other course regarding immunizations offered by a teaching entity approved by the Board.

    NAC 631.2564 Reporting of certain information concerning immunizations. A dentist or dental hygienist with a public health endorsement who administers immunizations, or a dental hygienist acting under the direct and immediate supervision of a dentist who administers immunizations, or a dental therapist acting under a written agreement with an authorized dentist to administer immunizations, shall report the information required for inclusion in the Immunization Information System established by the Department of Health and Human Services pursuant to NRS 439.265 and the regulations adopted pursuant thereto. NAC 631.2565 Written consent and medical history of patient required before administration of immunizations. 1. Written consent of the patient must be obtained before the administration of immunizations by an intranasal, intramuscular or subcutaneous injection. If the patient is a minor, the consent must be obtained from his or her parent or legal guardian. 2. A medical history must be reviewed before the administration of immunizations by an intranasal, intramuscular or subcutaneous injection. A patient should be asked to describe any current medical conditions or treatments, including, without limitation, medications, drug allergies, impending or past operations and pregnancy, and to give other information that may be helpful to the person administering immunizations by an intranasal, intramuscular or subcutaneous injection. The dental practitioner is not required to make a complete medical examination of the patient and draw medical diagnostic conclusions. If a dental practitioner suspects a medical problem and calls in a physician for an examination and evaluation, he or she may then rely upon that conclusion and diagnosis. Questions asked of and answers received from the patient must be permanently recorded and signed by the patient before the administration of immunizations by an intranasal, intramuscular or subcutaneous injection, and this record must be a permanent part of the patient’s record of treatment.

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  • NAC 631.2567 Maintenance of records. 1. Each record required to be made pursuant to NAC 631.009 to NAC 631.0095 and NAC 631.2561 to NAC 631.2568, inclusive,

    must be kept for at least 5 years, as provided in NRS 629.051, by the dental practitioner administering the immunization and the office who possessed the drugs administered. Such records must be available for inspection and copying by the Board or its representative, or any other authorized federal, state or local law enforcement or regulatory agency.

    2. Records required pursuant to this section may be maintained in an alternative data retention system, including, without limitation, a computer data processing system or direct imaging system, if: (a) The records maintained in the alternative system contain all the information required for a written record; and (b) The data processing system is capable of producing a printed copy of the record upon the request of the Board, its representative or any other authorized federal, state or local law enforcement or regulatory agency.

    NAC 631.2568 Confidentiality of records. 1. A dentist or dental hygienist with a public health endorsement who administers immunizations, or a dental hygienist acting under the direct and immediate supervision of a dentist who administers immunizations, or a dental therapist acting under a written agreement with an authorized dentist to administer immunizations, shall provide adequate security to prevent unauthorized access to confidential records of immunizations. If confidential health information is not transmitted directly between a dental practitioner and a physician, but is transmitted through a data communication device, the confidential health information must not be viewed or used by the operator of the data communication device unless the operator is specifically authorized to obtain confidential information pursuant to this subsection. 2. Except as otherwise provided in NRS 49.245, the confidential records of immunizations are privileged and may be released only to: (a) The patient or the authorized agent of the patient; (b) Physicians, dental practitioner, and pharmacists, when, in the professional judgment of the dental practitioner, such release is necessary to protect the health and well-being of the patient; (c) The Board or other federal, state or local agencies authorized by law to receive such information; (d) A law enforcement agency engaged in the investigation of a suspected violation involving a controlled substance or dangerous drug; (e) A person employed by any state agency that licenses a physician if such a person is engaged in the performance of his or her official duties; or (f) An insurance carrier or other third-party payor authorized by a patient to receive such information. 3. The provisions of this section must not be construed to affect or alter the provisions of NRS 49.215 to 49.245, inclusive, relating to the confidentiality of communications between a doctor and a patient.

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  • Agenda Item (d)(2):

    Licensing (NAC 631.028-220), including Regulations regarding Dental Therapy (NAC 631.205)

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  • LICENSING

    NAC 631.028 Applications for licensure; payment of fees. (NRS 631.190, 631.220, 631.345) 1. An application for licensure must be filed with the Executive Director on a form furnished by the Board. The application must be sworn to before a notary public or other officer authorized to administer oaths and accompanied by the fee required pursuant to NAC 631.029. 2. All such fees must be paid with an instrument which is immediately negotiable. (Added to NAC by Bd. of Dental Exam’rs, eff. 10-21-83; A 12-15-87; 4-3-89; 9-6-96; R169-01, 4-5-2002; R026-05, 12-29-2005)

    NAC 631.029 Schedule of fees. (NRS 631.190, 631.240, 631.345) The Board will charge and collect the following fees:

    Application fee for an initial license to practice dentistry if the applicant has successfully passed a clinical examination administered by the Western Regional Examining Board or a clinical examination approved by the Board and the American Board of Dental Examiners and administered by a regional examination organization other than the Board.................................................. $1,200

    Application fee for an initial license to practice dental therapy................................. 800

    Application fee for a specialty license by credential................................................ 1,200

    Application fee for a temporary restricted geographical license to practice dentistry 600

    Application fee for a temporary restricted geographical license to practice dental hygiene........................................................................................................... 150

    Application fee for a specialist’s license to practice dentistry.................................. 125

    Application fee for a limited license or restricted license to practice dentistry, dental therapy or dental hygiene.................................................................................................. 125

    Application and examination fee for a permit to administer general anesthesia, moderate sedation or deep sedation................................................................. 750

    Application and examination fee for a site permit to administer general anesthesia, moderate sedation or deep sedation................................................................. 500

    Fee for any reinspection required by the Board to maintain a permit to administer general anesthesia, moderate sedation or deep sedation.................................... 500

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  • Fee for the initial inspection and, if applicable, first re-inspection, of a facility required by the Board to ensure compliance with infection control guidelines................................................................................ 250

    Fee for each subsequent re-inspection of a facility required by the Board to ensure compliance with infection control guidelines …………… 50

    Fee for the inspection of a facility required by the Board to renew a permit to administer general anesthesia, moderate sedation or deep sedation.................... 350

    Biennial license renewal fee for a general license or specialist’s license to practice dentistry.......................................................................................................... 600

    Biennial license renewal fee for a restricted geographical license to practice dentistry.......................................................................................................... 600

    Biennial license renewal fee for a restricted geographical license to practice dental hygiene or dental therapy........................................................................................................... 300

    Biennial license renewal fee for a general license to practice dental hygiene hygiene or dental therapy............. 300

    Annual license renewal fee for a limited license to practice dentistry, dental therapy or dental hygiene........................................................................................................... 200

    Annual license renewal fee for a restricted license to practice dentistry.................... 100

    Biennial license renewal fee for an inactive dentist.................................................. 200

    Biennial license renewal fee for an inactive dental hygienist or dental therapist..................................... 50

    Fee for second or subsequent audit(s) to ensure compliance with Continuing Education requirements .................................... 100

    Reinstatement fee for a revoked license to practice dentistry, dental therapy or dental hygiene........ 500

    Reinstatement fee to return an inactive or retired dentist, dental therapist or dental hygienist or a dentist, dental therapist or dental hygienist with a disability to active status.................................. 300

    Fee for the certification of a license........................................................................ 25

    Fee for the certification of a license to administer nitrous oxide or local anesthesia... 25

    Fee for a duplicate wall certificate......................................................................... 25

    Fee for a duplicate pocket card receipt................................................................. 25

    Application fee for converting a temporary license to a permanent license............... 125

    Fee for an application packet for an examination.................................................... 25

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  • Fee for an application packet for licensure by credentials....................................... 25

    (Added to NAC by Bd. of Dental Exam’rs by R026-05, eff. 12-29-2005; A by R159-08, 4-23-2009; R066-11, 2-15-2012; R020-14, 6-23-2014; R119-15, 6-28-2016; R004-17, 5-16-2018)

    NAC 631.030 Provision of certain information and documentation by applicant for licensure; provision of certain additional information for licensure by endorsement; requirements for use of laser radiation in practice. (NRS 622.530, 631.190, 631.220, 631.230, 631.255, 631.272, 631.274, 631.312) 1. An applicant for licensure must provide the following information and documentation in his or her application: (a) The date and place of his or her birth; (b) Certification of graduation from an accredited dental school or college, from an accredited school or college of dental therapy, or from an accredited school or college of dental hygiene, whichever is applicable; (c) Whether he or she has applied for similar licensure in another state or a territory of the United States or the District of Columbia and, if so, the name of the state or territory of the United States or the District of Columbia, the date and the result of his or her application; (d) If he or she has practiced dentistry, dental therapy or dental hygiene in another state or a territory of the United States or the District of Columbia, certification from the licensing authority of each state or territory of the United States or the District of Columbia in which he or she has practiced or is practicing that he or she is in good standing and that there are not any disciplinary proceedings affecting his or her standing pending against him or her in the other state or territory of the United States or the District of Columbia; (e) Whether he or she has terminated or attempted to terminate a license from another state or territory of the United States or the District of Columbia and, if so, the reasons for doing so; (f) If he or she is not a natural born citizen of the United States, a copy of his or her certificate of naturalization or other document attesting that he or she is legally eligible to reside and work in the United States; (g) All scores obtained on the examination in which he or she was granted a certificate by the Joint Commission on National Dental Examinations and the date it was issued; (h) Whether he or she has ever been convicted of a crime involving moral turpitude or has entered a plea of nolo contendere to a charge of such a crime and, if so, the date and place of the conviction or plea and the sentence, if any, which was imposed;

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  • (i) Whether he or she has had any misdemeanor or felony convictions and, if so, any documents relevant to any misdemeanor or felony convictions; (j) Whether he or she has been held civilly or criminally liable in this State, another state or territory of the United States or the District of Columbia for misconduct relating to his or her occupation or profession; (k) Whether he or she has a history of substance abuse and, if so, any documents relevant to the substance abuse; (l) Whether he or she has been refused permission to take an examination for licensure by this State, any other state or territory of the United States or the District of Columbia, or any regional testing agency recognized by the Board and, if so, any documents relevant to the refusal; (m) Whether he or she has been denied licensure by this State, any other state or territory of the United States or the District of Columbia and, if so, any documents relevant to the denial; (n) Whether he or she has had his or her license to practice dentistry, dental therapy or dental hygiene suspended, revoked, subject to mandatory supervision, or placed on probation, or has otherwise been disciplined concerning his or her license to practice dentistry, dental therapy or dental hygiene, including, without limitation, receiving a public reprimand, in this State, another state or territory of the United States or the District of Columbia and, if so, any documents relevant to the suspension, revocation, supervision, probation or other discipline; (o) A copy of current certification in administering cardiopulmonary resuscitation; (p) Whether he or she is currently involved in any disciplinary action concerning his or her license to practice dentistry, dental therapy or dental hygiene in this State, another state or territory of the United States or the District of Columbia and, if so, any documents relevant to the reprimand or disciplinary action; (q) Two sets of certified fingerprint cards and an authorization form allowing the Board to submit the fingerprint forms to law enforcement agencies for verification of background information; (r) Whether he or she has any claims against him or her or has committed any actions that would constitute unprofessional conduct pursuant to NRS 631.3475 or NAC 631.230; (s) An application form that he or she has completed and signed which: (1) Is furnished by the Board; and (2) Includes, without limitation, a properly executed request to release information; (t) If applicable, th