Adult Facility/Community Site Reporting Form

These reports are to be filled out by an individual PHDH or a PHDH program. For reporting purposes, a PHDH program is defined as an established entity comprised of one or more PHDH providers. If a report is completed by a PHDH program, each PHDH providing any service at the site must be listed in Question 1.

All reports are to be provided by SITE, not date of service. The updated reporting form is designed to collect information for services provided throughout the duration of the quarter. EACH REPORT WILL INCLUDE DATA BY SITE OR FACILITY, AND NOT BY DATE OF SERVICE.

For further clarification, carefully read the following descriptions that correspond to each question found on the electronic reporting form.

Quarterly reports must be submitted by the 15th of the month following the previous quarter as follows: April 15, July 15, October 15 and January 15.

If there is any information requested in this report that is not clear to you, please refer to the "Adult Facility Reporting Form Instructions" for further clarification and instruction, at: www.mass.gov/dph/oralhealth and search under Topic Area "Dental Workforce."

1. Please account for all PHDH providers that delivered care to the same SITE OR FACILITY (see Question #2) throughout the quarter. Limited space is available.

If more than five providers were involved in delivery of services to this specific site, please email this information to Oral.Health@state.ma.us

PLEASE NOTE: In the past, PHDH providers submitted an individual report for each date of service. This is no longer necessary.

Name(s) and license number(s) of the PHDH(s) that delivered care at this site:

Please account for all PHDH providers that delivered care to the same SITE OR FACILITY (see Question #2) throughout the quarter. Limited space is available. If more than five providers were involved in delivery of services to this specific site, please email this information to Oral.Health@state.ma.us PLEASE NOTE: In the past, PHDH providers submitted an individual report for each date of service. This is no longer necessary. Name(s) and license number(s) of the PHDH(s) that delivered care at this site: #1 PHDH Name:
#1 License Number:
#2 PHDH Name:
#2 License Number:
#3 PHDH Name:
#3 License Number:
#4 PHDH Name:
#4 License Number:
#5 PHDH Name:
#5 License Number:

If more than five providers were involved in service to this specific site, please email this information to Oral.Health@state.ma.us