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Practice Name
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Owner Name
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Owner Email
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Practice Phone
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Legal Practice Name
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HIPAA Privacy Officer
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HIPAA Security Officer
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Dental Software
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How often is your Data backed up?
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On site and Off site
Onsite
Offsite
Data backup is
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Yes
No
Is your back up encrypted?
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OSHA Safety Coordinator
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Disinfectants Used
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Nitrous Oxide in office?
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Helium in office?
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Formaldehyde based products in office?
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How often do you test your dental unit water samples?
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Hand Pieces and Air/Water
Every water source in one doctor operatory and one hygiene operatory (testing different operatories each test period)
Every water source in every other (alternating) operatory, alternating every test period
Every water source in every operatory
Waterline testing sources
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What shock treatment is used?
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What continuous treatment is used?
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Eyewash Location
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Location of First Aid Kit
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Location of OSHA manual
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Location of SDS
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Name of Person in charge of SDS
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Who handles the contaminated laundry?
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Biohazard labels on the bags
Red bags
N/A - Disposables
When labeling or color-coding wet contaminate laundry, use
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Where are your sharps disposal locations?
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Evacuation Meeting Place
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Post Exposure Clinic
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Post Exposure Clinic Address
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Post Exposure Clinic Phone
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Would you like us to help you find a post-exposure clinic
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Radiation Safety Officer
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Yes
No
Digital x-rays?
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Film
Sensors
Phosphor Plates
Other
Type of Xrays
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How many x-ray machines do you have?
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Pano Machine?
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No
Yes
3D/CBCT X-ray Machine?
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Imaging Software Name
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Select...
Yes
No
Do you have lasers?
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Laser Safety Officer
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Yes
No
In-Office Controlled Substances?
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List all the CONTROLLED drugs you STORE in your office
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DEA Compliance Officer
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Chief Dental Officer
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Yes
No
Medicaid/CHIP or Medicare Provider?
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Medicaid Compliance Officer
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Location of Oxygen
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Location of Emergency Drug Kit
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Location of AED
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Pediatric Dentistry
General Dentistry
Oral Surgery
Periodontics
Prosthodontics
Endodontics
Anesthesia
Orthodontics
Primary Practice Discipline
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Pediatrics, Adolescents, Adults, Geriatrics & Special Needs
Pediatrics
Pediatrics & Adolescents
Pediatrics & Special Needs
Pediatrics, Adolescents & Adults
Pediatrics, Adolescents & Special Needs
Pediatrics, Adolescents, Adults & Special Needs
Adolescents
Adolescents & Adults
Adolescents, Adults & Geriatrics
Adolescents, Adults, Geriatrics & Special Needs
Adults
Adults & Geriatrics
Adults, Geriatrics & Special Needs
Geriatric
Geriatric & Special Needs
Special Needs
Patients Served
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Other
Prosthetics
Orthdontia
Oral Surgery
Endodontic
Restorative
Procedures Performed
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Other Procedures
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Name of Dentist
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General Anesthesia/ Level 4
Intravenous/ Level 3
Oral Conscious Moderate/ Level 2
Oral Conscious Minimal/ Level 1
Nitrous Oxide
Dentist Highest Sedation Permit
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Yes
No
Moderate Sedation, IV sedation, or General Anesthesia patients under 13?
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No
Yes
Papoose Board Used
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After Hours Phone Number
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