1. (a) In order to obtain public health supervision status, a dental hygienist shall complete a dental hygienist application for public health supervision status, to include the following:

   1. (1) Applicant's name and license number;
   2. (2) Applicant's current business and residential addresses, telephone numbers and primary email address either business or personal;
   3. (3) The name of the public health supervision program where the applicant is employed;
   4. (4) That the applicant agrees to limit any duties to those outlined in Den 402;
   5. (5) That the applicant agrees to follow appropriate infection control guidelines as recommended by the Center for Disease Control and Prevention; and
   6. (6) That the applicant agrees to advise participants in the program that the services provided do not replace regular examination by a dentist;
2. (b) The hygienist or supervising dentist shall send a summary of program results to the board at the one-year anniversary of the program's inception and each and every year after or, if the program lasts less than a year, at the end of the program; and
3. (c) The form shall be signed and dated by the applicant and the supervising dentist of the program.

Source. #10991, eff 12-9-15