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                            MISSISSIPPI COMMUNITY COLLEGE
                                Department of Dental Hygiene
                                      Jefferson Street
                                   Childers Hall 4th Floor
                                Booneville, Mississippi 38829
                                      (662) 720-7208

Dear Dental Hygiene Applicant,

Enclosed is a packet of information about the dental hygiene program at Northeast Mississippi
Community College. Please check to make sure that all of the following documents are included:
       1.    An application to Northeast Mississippi Community College.
       2.    A brochure listing prerequisite courses.
       3.    A preliminary application for the program.
       4.    A copy of the “Department Policy on Bloodborne Pathogens.”
       5.    A copy of the “Immunization Requirements for the Dental Hygiene Program.”
       6.    A final application with physical evaluation form.
       7.    A clinical observation form.
       8.    A projected student expenses list in addition to tuition, etc.
       9.    An example of the rating scale.

A new application should be completed each year if you wish to be considered. The preliminary
application should be completed and returned as soon as possible. The application deadline is
April 1. Your final application will not be complete until you have complied with the following
       1. Proof of MMR immunity (see “Immunization Requirements for the Dental
          Hygiene Program.”)
       2. A signed and completed “Physical Evaluation Form.”
       3. Official transcripts from each college previously attended must be on record
          in the admissions office.
       4. ACT scores (minimum of 17) must be on file in the admission office.
       5. Three letters of recommendation.
       6. A personal interview with the faculty.
       7. Proof of 16 hours of clinical observation.

Thank you for your interest in the program. If I can be of further assistance to you,
please contact me at (662) 720-7283.


Nick Alexander D.M.D.
Program Director

Revised 09/01/08
                           Northeast Mississippi Community College
                                Department of Dental Hygiene

                                          Preliminary Application

This information will be kept in a confidential manner. For a list of all requirements for application, please call 662-
720-7208 or send for an application packet from the Dental Hygiene Program, Northeast Mississippi Community
College, Cunningham Blvd., Booneville, MS 38829. If you have questions or concerns, please contact Dr. Nick
Alexander, Program Director, at 662-720-7283 or at the above address. Please type or print in black ink.
Full Name

                               Last                                  First                          Middle

Date of Birth


Home Phone                                                    Work Phone

Cell Phone                                                    E-mail

Person to Contact in
Case of Emergency
Name/Phone Number

Class Applying For (Fall 2009, Fall 2010, etc.)

Reason For Applying
To The Program

Previous High Schools and Colleges Attended                                        Years Attended
School                                                                            From           To

Miscellaneous Information                                                                  Yes         No
Have you ever been convicted of a felony offense?
Have you ever been arrested for drug use or abuse?
Have you ever been treated for drug use or mental illness?
Do you now use or have you ever used tobacco or tobacco products?

________________________________________________                          ____________________________
              Signature                                                                 Date
                           Northeast Mississippi Community College
                                Department of Dental Hygiene
                       Departmental Policy on Bloodborne Infectious Diseases

The most recent guidelines set forth by the Center for Disease Control in regard to bloodborne infectious diseases
such as HIV and Hepatitis B state that every healthcare worker who performs exposure-prone procedures (including
scaling and root-planning) should know his/her HIV status. If the healthcare worker becomes HIV-positive, he/she
must inform the governing professional body of the State. For dental hygienists in Mississippi, this is the State
Board of Dental Examiners. The Board of Dental Examiners will convene a meeting that will include experts in
infectious diseases in order to determine which procedures the dental hygienist may continue to perform.
The State of Mississippi’s legislature voted in 1996 to make the CDC guidelines (updated December 2003) official
for the State. Other states may have different solutions. However, the CDC has required every state to have a
written policy to deal with HIV-positive healthcare workers. Since you are training in Mississippi while at
Northeast, you must abide by this State law. In addition, you must realize that every patient has certain legal rights.
Specifically, if a dental hygienist knows that she/he is HIV-positive but does not disclose this information to her/his
patients before performing exposure-prone procedures, she/he has denied the patients their right to informed consent
and would be liable in a court of law.
Dental hygienists who are found by the State Board of Dental Examiners to pose a risk to patients while performing
exposure-prone procedures may choose alternative careers that use a dental hygiene background such as
pharmaceutical sales, education, insurance claims, or research.
The dental hygiene department does not intend to discriminate against any student with a bloodborne infectious
disease. However, it is our intent to follow current CDC guidelines in order to insure the welfare of the patients who
choose to obtain dental hygiene services through the program.
You are required to receive the Hepatitis B vaccines immediately upon admission to the program if you have not
already done so. Hepatitis B is a potentially deadly disease and the infectious disease of gravest concern to
healthcare workers.
As a student in the dental hygiene program, you should also be aware that the dental hygiene clinic at Northeast
routinely treats all patients for whom it is in their best interest to be treated. Therefore, we treat patients who are
HIV-positive, who have Hepatitis B and who have other infectious diseases. This is our legal, moral and ethical
responsibility. We do not discriminate against these patients in any way, nor do we discriminate on the basis of race,
creed, national origin, sexual orientation or religion. We will insist that you treat patients with no display of
hesitation, discrimination or aversion. You are expected to use “universal precautions” on every patient. “Universal
precautions” may be defined as the routine use with every patient of barrier protection such as gloves, masks, safety
glasses and fluid-resistant lab coats and the use of sterilization and disinfection methods for maintaining instruments
and working surfaces which will not harbor the transmission of pathogens. We do reserve the right to refuse
treatment to patients with active tuberculosis. The CDC has stated that these patients pose unique risks due to the
difficulty in killing the sputum-borne organism and the development of drug-resistant strains.
If you have questions or concerns about these policies, please contact Dr. Nick Alexander at (662-720-7283).
                      Northeast Mississippi Community College
                           Department of Dental Hygiene

           Immunization Requirements for the Dental Hygiene Program

The Board of Trustees of State Institutions of Higher Learning, in cooperation with the
Mississippi Department of Health, has issued regulations requiring that all students born after
1957 provide proof of immunity to measles (rubeola), mumps and rubella prior to being allowed
to enroll in class. This proof shall consist of the following:

          Documented history of two doses of measles (rubeola), mumps and rubella vaccine,
           given after January 1,1968, usually given as MMR. The first dose must have been
           given on or after the first birthday and the second dose at least one month or more
          Written documentation of serologic evidence of immunity to measles (rubeola) and
           rubella (a blood test): or,
          Documentation of a history of physician-diagnosed measles (rubeola). A history of
           rubella is not satisfactory to imply immunity.
Students admitted to health education programs that cause them to be potentially exposed to
blood and body fluids are required to receive the Hepatitis B series of vaccinations. You should
begin these in or before the pre-dental hygiene year as it takes several months to complete the
series of vaccinations. Series must be completed by May prior to acceptance. Current CDC
recommendation is that a Hepatitis B Antibody titer be run 1 – 2 months after the last shot of the
series. Proof of this titer must be submitted when entering the program in the fall.
If you have questions or concerns about these requirements, please contact Dr. Nick Alexander at
                                    Northeast Mississippi Community College
                                         Department of Dental Hygiene

                                              Physical Evaluation Form

This information will be kept in a confidential manner. For a list of all requirements for application, please call 662-
720-7208 or send for an application packet from Dental Hygiene Program, NEMCC, Cunningham Blvd.,
Booneville, MS. 38829. If you have questions or concerns, please contact Dr. Nick Alexander, Program Director, at
662-720-7283 or at the above address. Please type or print in black ink.
Applicant’s Name
                              Last Name                          First Name                   Middle Name
Permanent Mailing

    Phone Number                          Date of Birth                          Height                   Weight

                           The following information is to be provided and signed by a physician.
                                              Medical History of Applicant
    1.  Does the applicant              Yes    No Please indicate Yes or No to the following questions.
        have a history of
Tuberculosis                                              If yes, is the disease                    Yes            No
                                                          inactive and closely
Epilepsy or other seizure                                 If yes, what type of seizure
Disorder                                                  activity and how is it
Headaches                                                 If yes, please describe type of
                                                          headache, duration and treatment.

Heart Disease
Hay Fever, allergies or                                   If yes, please give cause of
dermatitis related to an allergy,                         the allergic reaction, extent
including drug reactions                                  and treatment.
Asthma                                                    If yes, please indicate
                                                          frequency and severity of
                                                          attacks and treatment.
Rheumatic Fever
Mitral valve prolapse                                     If yes, is there regurgitation
                                                          associated with the prolapse?
Hepatitis B or C                                          If yes, what is applicant’s
                                                          status at the present time?
Childhood diseases
Injuries or disabilities
                                 Northeast Mississippi Community College
                                      Department of Dental Hygiene

                                           Physical Evaluation Form

2. Physical Examination (Condition of)
Eyes                                                     Sinuses
Ears                                                     Skin
Oropharynx                                               Thyroid
3. Heart
Size                                                     Sound
Murmurs                                                  Rhythm
4. Abdomen
Scars                                                    Tenderness
Palpable Masses
5. Urine
Specific Gravity                           Protein                           Sugar
6. Skeletal
Alignment                                                Musculature
7. Has the applicant any physical or mental disabilities?                          Yes             No
Would the nature of the disability(ies) prevent the applicant from                 Yes             No
being able to do the work of dental hygiene (i.e., dental hygiene requires good
hand-to-eye coordination, sitting for long periods of time, repetitive motions of
the hands and wrists, and the application of knowledge in the treatment of

8. Immunizations and Tests
             Test                                 Date Given                             Results
                   Tuberculin Test
          Immunization                        Date                    Date                     Date
                     DPT Vaccine
                    MMR Vaccine
                     Polio Vaccine
    9.   In your opinion, is the applicant physically able to complete              Yes            No
         the course of study required for dental hygiene training?
Date                            Physician’s Signature

          Printed Signature

                                Northeast Mississippi Community College
                                       Department of Dental Hygiene
                                Estimated Expenses Additional to Tuition
Semester       Description of Items                                                     Cost
    1st        Instrument Kit                                                           $650.00
               Books                                                                     330.00
               Disposables & Film                                                        200.00
               Malpractice Insurance                                                       15.00
               2 Lab Coats @ $30.00                                                        60.00
               SADHA Dues (Student American Dental Hygienist’s Assn.)                      45.00

    2nd        Dental Handpiece                                                          420.00
               Books                                                                     130.00
               Disposables & Film                                                        200.00
               Radiology Badges                                                            37.50

 Summer        Books                                                                    $230.00

    3rd        Instrument Kit                                                            600.00
               Books                                                                     180.00
               Disposables & Film                                                        200.00
               Radiology Badges                                                            37.50
               Malpractice Insurance                                                       15.00
               SADHA Dues                                                                  45.00

    4th        Books                                                                       80.00
               Disposables & Film                                                        200.00
               Radiology Badges                                                            37.50

               Total Costs                                                              $3,712.50

Students are required to wear scrub suits in clinic and white shoes of their choosing. Scrub suits range from $18 to
$30 and can be purchased where ever desired.
All items listed are required expenses in order for a student to complete the curriculum with the exception of the
SADHA dues.
All graduating students apply to take the National Board Examination by mid-February. The fee for this is $175.00.
All students must take this examination. Students must then take licensure examinations for the individual states in
which they wish to practice. The Mississippi Board Examination costs $900. Tennessee participates in a regional
examination that is applicable to several states. The fee for that board is $925.

   All pre-dental hygiene students are required to complete a
   minimum of 16 observation hours in a dental office or the
                Northeast Dental Hygiene Clinic.

Student: ______________________________

Date: _______________        Hours: ______________

Date: _______________        Hours: ______________

Date: _______________        Hours: ______________

Date: _______________        Hours: ______________

Signature of Dentist or Hygienist
                Rating Scale for Dental Hygiene Technology
            Applicant Name __________________________________________

                       Date of Application _____________________

        CRITERIA                                    VALUE POINTS                             TOTAL
1  ACT Composite (list actual     ACT Composite = value points                      Points
   e.g. 20 ACT= 20 points         ACT____________
   e.g. 16 & below = 0 points
2. Overall College GPA            3.5-4.0                                           4
                                  3.0-3.49                                          3
                                  2.5-2.99                                          2
                                  2.25-2.49                                         1
3. Academic courses taken             COURSE        GRADE     REPEAT     POINTS
   with assigned point value as    BIO 2514
   follows:                        (A & P I)
     A = 5 points                  BIO 2524
     B = 3 points                  (A & P II)
     C = 1 point                   FCS 1253
                                   BIO 2924
    All D’s, F’s, and W’s in       (Micro)
    the required pre-requisite     ENG 1113
    courses will receive a one     PSY 1513
    point deduction per grade.     CSC 1113
    (-1)                           MAT 1233
                                   SOC 2113
                                   SPT 1113
                                   Fine Art Elec

                                                         Subtotal _________

4. Number of non-required         (Maximum 5) x 1
   science courses taken with a                          Subtotal _________
   grade of C or higher.
5. Professional Commitment:       ___BS or higher degree                            3
   Documentation must be in       ___Allied Health program certificate/ licensure   2
                                  ___Worked in dental related field for more than   2
   the Program Director’s            one year
   office by deadline dates to    ___High School Health Occupations course          1
   earn point(s)—This is the
   student’s responsibility
                                                   GRAND TOTAL OF POINTS

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