School/Pediatric 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 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 PER GRADE, AND NOT BY DATE OF SERVICE.

For further clarification, carefully read the following descriptions that correspond to each question found on the updated 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 "Pediatric Site Reporting Instructions" for further clarification and instruction, at: www.mass.gov/dph/oralhealth and search under Topic Area "Dental Workforce."
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1. Please account for all PHDH providers who delivered care to the same grade level and site (see questions #2 & #3) throughout the quarter. Limited space is available.

If more than five providers were involved in delivering 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 site and date of service. This is no longer necessary.

NAME(S) AND LICENSE NUMBER(S) OF THE PHDH(S) THAT PROVIDED CARE AT THIS SITE:

IF MORE PHDH PROVIDERS WERE INVOLVED IN SERVICE FOR THIS GRADE AT THIS SITE THAN CAN FIT ON THE PREVIOUS SECTION, PLEASE EMAIL THIS INFORMATION TO Oral.Health@state.ma.us.
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2. The site name, address, city/town, and zip code should be provided.

SCHOOL/PEDIATRIC SITE INFORMATION:
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3. A list of grades ranging from “Preschool” to “9th-12th Grade” will be available for selection.

Only a single grade level, with the exception of the combined 9th-12th grades, can be selected as each report is now grade specific.

If multiple grades are served at a site, multiple forms must be submitted. For example, if over the course of a quarter, screenings were provided for 1st and 2nd graders at "X Elementary" and 2nd graders at "Y Elementary." One survey should be completed with information pertaining to the 1st grade at "X Elementary," another for the 2nd grade at "X Elementary," and yet another for 2nd grade at "Y Elementary."

Remember, each of these reports should contain only information relating to a single grade at a single site (see question #2).

“Preschool” includes any student younger than kindergarten age.

GRADE SERVED (*THIS WILL BE THE ONLY GRADE ALL OF THE FOLLOWING QUESTIONS WILL REFER TO)