Fall 2027 Dental Hygiene Application
Dear Dental Hygiene Applicant: Thank you for your interest in the Blinn College District Dental Hygiene Program. Enclosed is the complete information packet for the program, along with an Application Procedure guide. You will find information regarding the admission procedures; required courses (both general academics and dental hygiene courses); estimated cost; and the application, observation, community service, and reference forms. The Dental Hygiene Program is a two-year program that begins in the fall semester each year in Bryan, TX. Enrollment is limited to 14 each year. Blinn College District offers the Associate of Applied Science (A.A.S.) degree in Dental Hygiene. Upon successful completion of the program, the student is awarded the A.A.S. in Dental Hygiene and is eligible to sit for national and regional licensing examinations. Admission to Blinn College District does not imply or guarantee admission to the Dental Hygiene Program. The program is accredited by the American Dental Association’s Commission on Dental Accreditation (CODA). A minimum grade point average of 2.5 is recommended. Applicants must have earned at least a “C” in all academic courses required in the program. Selection is based on GPA, grades in the required general academic courses, grades in the sciences, ATI TEAS, a general category which includes college credit and/or degrees awarded, letters of recommendation, employment history, observation, and community service activities. An interview is not required. Notification of results will be made via email during March 2027. Please thoroughly read the application packet and follow all directions. Failure to do so may result in a reduction in total points awarded or disqualification of the application. Your application packet will not be processed unless ALL steps are completed within the scope of the criteria and delivered or postmarked no later than Feb. 1 , 2027 . No exceptions will be made. Please do not hesitate to contact the Dental Hygiene Program office at (979) 209-8066 or Nikki.Pratt@blinn.edu. Sincerely, Lisa K. Wiese, M.S, R.D.H. Lisa K. Wiese, M.S., R.D.H. Program Director, Professor
Communicable Disease Policy Hepatitis B Vaccination All health care providers should be immunized against the Hepatitis B virus as well as childhood diseases. Hepatitis is an inflammation of the liver. There are several types but the greatest risk to health care workers is Hepatitis B (HBV). Available since 1982, the Hepatitis B vaccine is considered safe and effective and is recommended for the prevention of HBV infection by the Centers for Disease Control and Prevention (CDC). The Blinn College Dental Hygiene Program strictly adheres to and routinely practices the “Standard Precautions” against bloodborne pathogens enforced by OSHA (Occupational Safety and Health Administration) and recommended by the CDC. Communicable Disease - Student Admission Dental hygiene applicants are considered without regards to race, color, creed, age, marital status, national origin, disability, or gender. Otherwise qualified applicants with an active communicable disease, including sero-positivity for Hepatitis B (HBeAg) and/or HIV, receive equal consideration. Applicants should note, however, that some state boards of dental examiners’ rules and regulations mandate that a dental hygienist who is HBeAg seropositive or HIV seropositive must report this fact to the Board who may limit the type of procedures that the student may be able to perform. This potential restriction may preclude the dental hygiene student with an infectious disease from performing tasks/procedures essential to the completion of the requirements for graduation from the dental hygiene program. Communicable Disease – Patient Treatment Students in the dental hygiene program will provide treatment to patients after competency has been demonstrated in a laboratory setting. Faculty will provide direct supervision and consultation to oversee student and patient safety. To fully develop clinical skills, students must treat all scheduled patients. Treatment will be provided to all patients regardless of their race, color, sex, religion, national origin, handicap, or other human condition. If a student has a concern about treating a patient, the student should discuss this situation with the clinical supervisor. Refusal to treat the patient may be cause for dismissal from the program. Please call the Dental Hygiene Department at 979-209-7 283 , if you need further clarification.
DENTAL HYGIENE PROGRAM COURSE INFORMATION Pre-requisite Courses CHEM 1305 AND 1105 or 1411 or 1405 4 BIOL 2401* Anat. and Physiology I 4 BIOL 2402* Anat. and Physiology II 4 ENGL 1301 Comp. and Rhetoric 3 15 credit hours Semester I (Fall) DHYG 1301 Oral Anat/Hist/Embryology 3 DHYG 1304 Dental Radiology 3 DHYG 1431 Pre-Clinical DH 4 DHYG 1227 Pev. DH Care 2 12 credit hours Semester II (Spring) DHYG 2201 Contemporary DH Care I 2 DHYG 1219 Dental Materials 2 DHYG 1339 Gen/Oral Path 3 DHYG 1260 Clinical DH I 2 DHYG 1235 Pharmacology 2 *BIOL 2420 Microbiology for Non-Science Majors 4 OR BIOL 2421 Microbiology for Science Majors 15 credit hours Summer I DHYG 1161 Clinical DH II 1 1 credit hour Semester III (Fall) DHYG 1207 Gen/Dent. Nutrition 2 DHYG 1311 Periodontology 3 DHYG 2262 Clinical DH III 2 DHYG 2231 Contemporary DH Care II 2 *SOCI 2326 Social Psychology OR PSYC 2319 Social Psychology 3 12 credit hours Semester IV (Spring) DHYG 1215 Comm. Dentistry 2 DHYG 2102 Applied Comm. Dentistry 1 DHYG 2153 DH Practice 1 DHYG 2363 Clinical DH IV 3 *PHIL 2306 Introduction to Ethics 3 *SPCH 1311 or 1315 or 1321 3 13 Credit hours Total credit hours: 68 *Denote General Education Courses Program Director: Lisa K. Wiese, M.S.,R.D.H. Phone Number: (979) 209-7275 E-mail address: Lwiese@blinn.edu WHAT IS THE COST? The student’s greatest expense is at the beginning of the first semester of each year when instruments and supplies must be purchased. Tuition and fees may vary due to student’s residency status determined by Blinn College. The costs listed below are approximate costs per year based on Out-of-District fees, and for DHYG courses only. First Year: Fall and Spring Tuition and fees ~ $7,600 - $7,800.00 Supplies, Instruments ~ $ 3 , 00 0 .0 0 Books - DHYG only ~ $750 - $1,000.00 Uniforms ~ $200.00 Summer Semester: Tuit ion and fees ~ $ 1 , 300.00 Second Year: Fall and Spring Tuition and fees ~ $6, 70 0 - $6,800 .00 Supplies, Instruments ~ $1,100 - $1,200.00 DHYG Books ~ $ 4 50 - $ 600 .00 Uniforms ~ $ 2 00.00 Total Est. Cost Range ~$ 21 , 0 00 - 2 2 , 0 00 .00 Optional Equipment Loupes and Light ~ $1, 3 00.00 Approximate fees for licensure exams: TSBDE Jurisprudence Exam ~ $75.00 National Board Dental Hygiene Exam – computer based ~ $600.00 Regional Examining Board - Clinical~ $1,200- $1,300.00 Criminal Background Check And Drug Screening ~ $150- $175.00 Licensing application: Texas ~ $125.00- $150
2027 Points Worksheet WEI G HT CATEGORY POINT VALUE MAX. PTS TOT AL PTS. 15 % Overall College GPA GPA X 3.75 15 28% Completed Academic Courses **BIOL 2402 no older than 5 years; **BIOL 2420 or 2421 no older than 3 years; **Higher level course with higher grade, gets higher points; Science course weight : A= 5; B=3; C=0 pt s . CHEM 1405 OR CHEM 1411 OR CHEM 1305 & 1105 BIOL 2401 BIOL 2402 BIOL 2420 OR BIOL 2421 Gen. acad. Course weight: A=2; B=1; C=0 pts. ENGL 1301 SPCH 1311 OR 1315 OR 1321 SOCI 2326 OR PSYC 2319 OR SOCI 1301 & PSYC 2301 PHIL 2306 28 46% ATI-TEAS Weights of Subjects Reading – 40% Math – 15% Science – 10% English – 35% Subject % Score Multiplier Points Reading .184 Math .069 Science .046 Eng lish .161 46 11% Other Category Requirement Earned Letters of Rec. 3=1 pt. Prof essional Cert. 1 pt Observation Hrs 1 pt Work exp. Or Military (2 yrs.) 12 mos. = 0.5 18 mos. = 1.0 24 mos = 1. 5 Comm. Serv. Hours Points 1-12 0.5 13-25 1.0 26-39 1.5 40+ 2.0 Hours/degree Points 36 - 48 0.5 49+ 1 AAS/AA/AS 2 Last sem .prior to BS /BA conferring 3 BS/BA/BAAS 3.5 MS/MA/Med 4 .5 11 Total 100
ATI TEAS for Health Sciences Check the link below for the most up to date information regarding testing. https://www.blinn.edu/testing/health-sciences-ati-teas.html ATI TEAS C OMPONENTS • Reading: 55 minutes (45 questions) • Mathematics: 57 minutes (38 questions) • Science: 60 minutes (50 questions) • English: 37 minutes (37 questions ) S TUDY G UIDE I NFORMATION ATI TEAS Study Manual and the ATI TEAS Online Practice Assessment A & B are currently available at www.atitesting.com to set yourself up for success. Ask your college and local libraries about access to practice guides and testing databases. T ESTING Your ATI TEAS must be taken in-person at a testing center near you. The test is offered at Blinn College, but you may also take it at any college or private testing center. Online proctoring is no longer allowed. Exemptions to this rule may be granted by the director as needed for distance problems. You are limited to completing this test 2 times per application cycle (Feb. 1, 2026-January 31, 2027). T EST V ERSION We will only accept score sheets from Version 7 of the TEAS test. S CORE R EPORT To acquire your score report for your application packet, please access your ATI TEAS account and print the score sheet(s) officially titled Individual Performance Profile (IPP). Please submit the sheet with all four subject areas, but it is not necessary to include the other sections of the IPP. Instruction on how to access your IPP can be found at https://help.atitesting.com/what-is-an-individual-performance- profile-for-teas/ We accept the highest score in each category and multiple score sheets may be submitted as necessary. Score sheet must have your name and date of test on it. Scores do not expire.
1 of 3 BCDH Application Procedures Guide Blinn College Dental Hygiene Application Procedures Guide 1.APPLY TO BLINN COLLEGE DISTRICT: If you are not a current student at Blinn College District, pleaseapply at this time. Go to https://www.blinn.edu/admissions/index.html for instructions. Select PDHY (Pre-dental hygiene) as your major and indicate Spring 2027 as your intended semester even thoughthe program does not begin until fall 2027. Request official transcripts from all colleges that you haveattended and send directly from the awarding institution to Blinn College District Admissions .Electronic transmission of official transcripts is accepted at Blinn College. If you are in-progress withcoursework during the fall 2026 semester, please request transcripts after the fall grades are posted.This will allow time for your transcripts from outside institutions to be evaluated for transfercoursework. 2.Financial Assistance: Blinn College District provides financial assistance towards college costs in theform of loans, grants, scholarships, and work study. For more information, contact the personnel in theOffice of Financial Aid at 979-209-7230 or visit their website at https://www.blinn.edu/financial- aid/index.html . 3.Information Sessions : Blinn College Dental Hygiene offers free, in-person information sessions at ourcampus in Bryan, TX led by a current instructor of dental hygiene. Attending an information session isnot mandatory. For dates on our information sessions, please visit https://www.blinn.edu/dental- hygiene/information-session.html . 4.Deadlines: Complete the Dental Hygiene Program application form, enclose all supporting documents,and mail or deliver no later than Monday, Feb. 1, 2027, 5:00 p.m. to the Dental Hygiene Program officeat: Mailing Address : Physical Address: Blinn College District Blinn College Dental Hygiene ATTN: Dental Hygiene Program 301 Post Office St. P.O. Box 6030 Bryan, TX 77801 Bryan, TX 77805-6030 5.Proof of Texas Success Initiative (TSI) Status : Applicants must be “ college ready ” in all sections basedon results of assessment or through exemption. Your TSI standing is generally indicated on your officialcollege transcript. For additional information, please visit: https://www.blinn.edu/testing/tsi/index.html
2 of 3 BCDH Application Procedures Guide 6.Transcripts and Grades: In addition to the electronic transcripts submitted to admissions, pleaseenclose official transcripts or notarized through a third party transactor in your dental hygiene application packet. Include all colleges you have attended, including Blinn College. Each transcript should remain in its sealed envelope and will generally be marked with a school seal and/or signature on the back of the envelope. Dual Credit students should submit the transcript of the college theyattended, not their high school transcript, to receive credit for classes completed. Applications withmissing or opened transcripts may be disqualified. All educational classes must be “C” or above to be considered towards a dental hygiene degree.However, only those courses achieved with a “B” or better are considered when determining thepoints value for admission. Anatomy & Physiology II must have been completed within the past 5 years(no earlier than fall 2021) and Microbiology must have been completed within the past 3 years (noearlier than fall 2023). Points will not be awarded for classes completed if the appropriate transcript is not included in the application. 7.ATI TEAS: Complete the ATI TEAS test. Scores from the ATI TEAS will not be sent directly to theprogram. Print your Individual Performance Profile (IPP) score sheet(s) and enclose them in yourapplication packet. The IPP score sheet reports the scores for all 4 subject areas, not just the overallscore. Your score sheet must have your name and the date of the test on it. Test scores do not expire,and older results are acceptable in this application. Online proctored scores are no longer accepted.We use the highest score in each category, so you may include multiple score sheets. Additionalinformation on ATI TEAS testing is found on the “ATI TEAS for Health Sciences” document in thisapplication. 8.Recommendation forms : Submit three (3) completed recommendation forms from individuals in thecommunity (employers, members of the clergy, teachers, civic leaders, etc.) unrelated to you thatwould be familiar with your qualifications for the dental hygiene profession. You must use 3 uniquesources (i.e., 1 employer/co-worker, 1 teacher, 1 long-time family acquaintance, etc.). Personal friendsare not acceptable. Please attach an envelope to the form for the recommender and use the provided form. Letters/forms must be received in individual sealed envelopes and submitted with your complete packet. 9.Observations: Observation of a registered dental hygienist is a requirement for application. Theexperience will help you see, first-hand, the day-to-day functions of a dental hygienist and will affordyou the opportunity to see how his/her position relates to the function of the total dental careprofession. You must observe a minimum of 16 hours. Please have the hygienist(s) document yourobservation time on the enclosed observation log. Dental assistants must observe, as well. Simplyworking as a dental assistant will not substitute for direct observation unless you are a dental hygieneassistant. Applicants may NOT observe a dentist providing dental hygiene services. Observation mustoccur between the following dates: Feb. 1, 2026 – Jan. 31, 2027. No exceptions.
3 of 3 BCDH Application Procedures Guide 10.Community Service: Community service is not required but is highly encouraged to boost the points total in your application. Community service comes from the heart; where you volunteer is entirelyyour choice and should be with an entity that is near and dear to you. Points will be awardedincrementally for up to 40 hours. You may use the enclosed form for documentation, or you mayprovide a signed letter, on letterhead, from a supervisor. Community service must occur between thefollowing dates: Feb. 1, 2026 – Jan. 31, 2027 . 11.Verification of Employment: Please provide letters from employers for verification of employment.Points will be awarded for work experience totaling up to two years, either part-time or full-time, inany field. 12.Professional Certifications : Applicants can earn one point for holding a current professionalcertification or license in a field that requires such certification for employment opportunities.Examples include Certificate of Cosmetology, Electrician, Certified Teacher, etc. Basic registrations suchas Registered Dental Assistant (RDA) are not accepted. Please include a copy of your certificate withyour ID number visible. Certificates may be verified. 13.Interviews are NOT a part of the application process. All points will be calculated based on the pointsrubric provided in the application. 14.Additional Documentation: Please do NOT submit unnecessary documentation such as resumes,photos, immunization records, CPR cards, proof of extracurricular activities, or high school transcripts. 15.Submission of Application : Please submit your application packet, which includes the application form,official transcripts, recommendation forms, ATI TEAS, proof of employment, copies of certifications,and community service activities in a 9 X 12 envelope. The packet must be postmarked or delivered to the Dental Hygiene office no later than Monday, Feb. 1, 2027, 5:00 pm. Failure to meet this deadline will disqualify your application for the fall 2027 class. Each applicant is responsible for ensuring that the Blinn College Dental Hygiene Program has received all information. Any application that is incomplete will not be considered for the fall 2027 start date. 16.Verification of Delivery : It is highly recommended that you keep proof of mailing and/or request areturn receipt if mailing via US mail, UPS or FedEx. Blinn College Dental Hygiene will also send an emailto the address provided verifying that your packet has been received within 3- 5 business days.
Blinn College Dental Hygiene Program Application Completion Form Fall 2027 ( Please complete and attach to the front of your application packet after you review, validate and sign) Name_________________________Blinn ID#____________DOB (Month/Day ONLY) __________ Please place a check mark (√) by all those items included in this packet, sign and date this form prior to mailing 1. Program Application (completed and signed) ________ 2.College Transcripts (enclosed) Transcripts must be official and in sealed envelopes Name of Institution a.__________________________________________________ b.__________________________________________________ c.__________________________________________________ d.__________________________________________________ 3.ATI TEAS- (scores enclosed)________ 4.Recommendation Forms (enclosed) Recommendation forms must be in sealed envelopes. Name of Recommender a.__________________________________________________ b.__________________________________________________ c.__________________________________________________ 5.Community Service Log________ 6.Employment /Military service verification________ 7.Professional Certification________ __________________________________________________________________ ______________________________ Student Signature Date
(Continue on next page) SECTION A – GENERAL INFORMATION FALL 2027 BLINN COLLEGE DENTAL HYGIENE PROGRAM APPLICATION 1.Date: 2.DOB: (month/day only )Blinn College ID# 3.Full Name: (Last) (First) (MI) 4.Other names under which credentials may be received: 5.Permanent Address: (Number and Street) (City) (State) (Zip) 6.Mailing Address: (Number and Street) (City) (State) (Zip) 7.Telephone Number: (h) () cell ( ) 8.E-mail Address you use: 9.Emergency Contact : (name/number) 10.Are you a citizen or permanent resident of the United States?Yes No 11.List all educational institutions (colleges, universities, and professional schools) in order ofattendance. Do not omit the name of any institution where you have been a student. If necessary,use a separate sheet of paper. School Name Credit Hours Degree/ Certificate Date Awarded or Expected 12.Are you eligible to return to each of these institutions?Yes No If no, please explain: 13.Have you previously attended any health related programs? Yes No If yes, complete the following information: School Name: Address: Dates of Attendance: Graduated: Yes No Date: Type of Program:
(Continue on next page) SECTION D – TESTING SECTION C – PROFESSIONALISM 14. E MPLOYMENT : Beginning with the most recent, please list years of employment, and/or militaryservice. Enclose in application packet letters and/or signed statements from employers or DD-214,verifying up to 2 years of employment tenure/military status. Employer/Military Experience Phone Dates Job Title to to to Total number of years/months of employment and/or military service: 15. C OMMUNITY S ERVICE : Enclose Community Service Log or letters providing dates of activities onletterhead from a supervisor. Total hours spent in community service activities from Feb. 1, 2026-Jan. 31, 2027: . 16. R ECOMMENDATION F ORMS : Complete and sign the top portion of the forms, “Recommendationfor Dental Hygiene”. Three (3) completed recommendation forms must be received in sealed envelopes and enclosed in your application packet. References may be validated by our office. 17. P ROFESSIONAL C ERTIFICATIONS : Enclose a copy of any current Professional Certifications you mayhave. 18. O BSERVATION H OURS : Enclose in your application packet the signed Observation Log . 19. ATI-TEAS : Enclose your Individual Performance Profile score sheet in your application packet. Scoresheet must have your name and date of test on it. 20. TSI / TSIA : Verify that you are ‘College Ready’ or ‘Exempt’ for all portions of the TSI. Applicantswho have not completed the college assessments will be disqualified. (initial) I am TSI/TSIA complete. SECTION B - WORK EXPERIENCE
(Continue on next page) SECTION F - MISCELLANEOUS 21. T RANSCRIPTS : Enclose official, unopened transcripts from all education institutions attended in your application packet. Missing transcripts may result in a denial of credit for classes completed and/ordisqualification of your application. Transfer classes on another college’s transcript are not accepted asofficial.(initial) I have enclosed official transcripts from all colleges I attended. 22. G RADES : Complete the following table for required courses within the dental hygiene curriculum: A&P 2 must have been completed within the past 5 years. (no earlier than Fall 2021)Microbiology must have been completed within the past 3 years. (no earlier than Fall 2023) Gen. Academic courses required for dental hygiene degree Grade (A - F) * if Repeated OR IP= In Progress NT= Not Taken Semester Completed College/ University Location where completed Your Course Equivalent (if not exact course listed) CHEM 1405 or CHEM 1411 or CHEM 1305 w/1105 Intro. To Chemistry BIOL 2401 A & P I BIOL 2402 A & P II BIOL 2420 or 2421 Microbiology ENG 1301 Comp. & Rhetoric SPCH 1311 or 1315 or 1321 Speech SOCI 2326 or PSYC 2319 or SOCI 1301 w/ PSYC 2301 Social Psychology PHIL 2306 Intro to Ethics 23. B ACKGROUND C HECKS : A criminal background check and drug screening will be required for allapplicants who are offered a position. Further information will be provided if you are accepted into the program. If you have been convicted of a misdemeanor or felony, it is suggested that you complete a Criminal History Evaluation (CHE) from the Texas State Board of Dental Examiners to ensure licensure eligibility upon graduation from the program. Graduation from the program does not ensure eligibility to be licensed and practice dental hygiene in the state of Texas. http://www.tsbde.texas.gov/licensing/criminal-history- evaluation/ If interested in licensure in other states, please reference the individual states’ dental boards for information. SECTION E - COURSES AND CONTINUING EDUCATION FORM
NOTE Possible Board Exam/Employment Qualifiers: o Conviction of a felony or misdemeanor that relates to the duties and responsibilities ofthe licensed occupation. o Dependence on alcohol/drugs and other chemicals o Dismissal from employment due to unprofessional or dishonorable conduct o Restriction, suspension, revocation or probation of licensure in another jurisdiction withinthe past 10 years o Failure to report disciplinary action received in another jurisdiction. For further information, contact http://tsbde.texas.gov/licensing/criminal-history-evaluation/ 22.Signature: I certify that the information provided in this application is correct and complete. I understand that omissionor falsification of information is grounds for exclusion or dismissal. If accepted into the program, I agree tomeet all entrance requirements and to confirm and abide by the letter and the spirit of the rules, regulationsand procedures of Blinn College and this program. In addition, I am aware that I will be subject to a criminalbackground check and drug testing (cost to the applicant) prior to beginning the dental hygiene program, ifaccepted. I have received a copy and read the Application Procedures Guide and the Communicable Diseasepolicy statement. Signature Date Is your application complete? Please use the enclosed checklist to ensure your application is complete. Submit in a 9x12 envelope. Have you contacted the Dental Hygiene Program for answers to your questions concerning thisapplication? We are very happy to help you! Submit the Dental Hygiene Application and all correspondence to: Blinn College ATTN: Dental Hygiene Program P.O. Box 6030 Bryan, TX 77805-6030 Or deliver to: 301 Post Office St. Bryan TX 77801 You are responsible for ensuring that all information has been received by the Blinn College Dental Hygiene Program. Any application that is not complete cannot be considered for entrance into the program.
Blinn College Dental Hygiene Program Community Service Log Student’s Name:_________________________________Month/Day of Birth:____________________ *Community Service must occur between the following dates: Feb. 1, 2026 – Jan. 31, 2027 Date of Event/Place_______________ Total hours of participation______________________________ Name of Event___________________________________________________________________________ Address___________________________________________________________________________ Phone#___________________ Name of Supervisor__________________________ Supervisor’s Signature_______________________________________Date______________________ Date of Event/Place_______________ Total hours of participation______________________________ Name of Event___________________________________________________________________________ Address___________________________________________________________________________ Phone#___________________ Name of Supervisor__________________________ Supervisor’s Signature_______________________________________Date______________________ Date of Event/Place_______________ Total hours of participation______________________________ Name of Event___________________________________________________________________________ Address___________________________________________________________________________ Phone#___________________ Name of Supervisor__________________________ Supervisor’s Signature_______________________________________Date______________________ Date of Event/Place_______________ Total hours of participation______________________________ Name of Event___________________________________________________________________________ Address___________________________________________________________________________ Phone#___________________ Name of Supervisor__________________________ Supervisor’s Signature_______________________________________Date______________________ TOTAL HOURS: _________________________
Blinn College Dental Hygiene Program Observation Log Observation of Registered Dental Hygienist Only Student’s Name_______________________________________Blinn ID#:_________________________ * Observation must occur between the following dates: Feb. 1, 2026– Jan. 31, 2027 Date of Observation____________________ Total Hours Observed______________________________ Name of Office___________________________________________________________________________ Office Address___________________________________________________________________________ Phone#___________________ Name of Hygienist_____________________________License#_________ Hygienist Signature_____________________________________________Date______________________ Date of Observation____________________ Total Hours Observed______________________________ Name of Office___________________________________________________________________________ Office Address___________________________________________________________________________ Phone#___________________ Name of Hygienist_____________________________License#_________ Hygienist Signature_____________________________________________Date______________________ Date of Observation____________________ Total Hours Observed______________________________ Name of Office___________________________________________________________________________ Office Address___________________________________________________________________________ Phone#___________________ Name of Hygienist_____________________________License#_________ Hygienist Signature_____________________________________________Date______________________ Date of Observation____________________ Total Hours Observed______________________________ Name of Office___________________________________________________________________________ Office Address___________________________________________________________________________ Phone#___________________ Name of Hygienist_____________________________License#_________ Hygienist Signature_____________________________________________Date______________________
Blinn College Dental Hygiene Program Recommendation Form Name of Applicant ___________________________________ To assure that your records are held in compliance with the law as stated below*, please check one: _____ I GIVE UP my right to access of this form. _____ I DO NOT GIVE UP my right to access of this form. Applicant Signature______________________________________ Date _________ The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program. *Please Note : FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student/ applicant the right to waive access. See above for the student’s/applicant’s choice regarding confidentiality I have known the applicant in the following capacity and location: _____________________________________________________________ I have known the applicant for _________ years _________ months. I would evaluate the applicant as follows: EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE NOT KNOWN Attitudes toward others (caring, respect) Ability to work with others Ability to communicate orally Ability to communicate in writing Independence Initiative Ability to accept responsibility Presentation of self (poise, courtesy, language) Potential for growth RECOMMENDATION: _____ Strongly Recommend _____ Recommend _____ Recommend with Reservation _____ Not Recommend Comment (s): Signature ________________________________________________ Date __________________ Position ________________________ Address ________________________________________________________________________________________________________ Telephone ______________________ Please return this form to the applicant in a sealed envelope.
Blinn College Dental Hygiene Program Recommendation Form This reference form is to be submitted with the application in a sealed envelope. References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has had professional relationships. References from family members or friends are NOT accepted. Submitting inappropriate references will result in fewer points than the maximum allows for this portion of the application process. Name of Applicant ___________________________________ To assure that your records are held in compliance with the law as stated below*, please check one: _____ I GIVE UP my right to access of this form. _____ I DO NOT GIVE UP my right to access of this form. Applicant Signature______________________________________ Date _________ The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program. *Please Note : FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student/ applicant the right to waive access. See above for the student’s/applicant’s choice regardingconfidentiality I have known the applicant in the following capacity & location : _______________________________ _______ ___________________ I have known the applicant for _________ years _________ months .I would evaluate the applicant as follows: EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE NOT KNOWN Attitudes toward others (caring, respect) Ability to work with others Ability to communicate orally Ability to communicate in writing Independence Initiative Ability to accept responsibility Presentation of self (poise, courtesy, language) Potential for growth RECOMMENDATION: _____ Strongly Recommend _____ Recommend _____ Recommend with Reservation _____ Not Recommend Comment (s): Signature ________________________________________________ Date __________________ Position ________________________ Address ________________________________________________________________________________________________________ Telephone ______________________ Please return this form to the applicant in a sealed envelope.
Blinn College Dental Hygiene Program Recommendation Form This reference form is to be submitted with the application in a sealed envelope. References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has had professional relationships. References from family members or friends are NOT accepted. Submitting inappropriate references will result in fewer points than the maximum allows for this portion of the application process. Name of Applicant ___________________________________ To assure that your records are held in compliance with the law as stated below*, please check one: _____ I GIVE UP my right to access of this form. _____ I DO NOT GIVE UP my right to access of this form. Applicant Signature______________________________________ Date _________ The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program. *Please Note : FERPA grants a student/applicant access to his/her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student/ applicant the right to waive access. See above for the student’s/applicant’s choice regardingconfidentiality I have known the applicant in the following capacity & location: _________________________________________________________ I have known the applicant for _________ years _________ months. I would evaluate the applicant as follows: EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE NOT KNOWN Attitudes toward others (caring, respect) Ability to work with others Ability to communicate orally Ability to communicate in writing Independence Initiative Ability to accept responsibility Presentation of self (poise, courtesy, language) Potential for growth RECOMMENDATION: _____ Strongly Recommend _____ Recommend _____ Recommend with Reservation _____ Not Recommend Comment (s): Signature ________________________________________________ Date __________________ Position ________________________ Address ________________________________________________________________________________________________________ Telephone ______________________ Please return this form to the applicant in a sealed envelope.