1. (a) Each applicant for approval of a program under public health supervision shall provide the following on the "Application for Dental Program Approval under Public Health Supervision" form:

   1. (1) Supervising dentist's name and license number;
   2. (2) Supervising dentist's primary business address, business telephone number and primary email address either business or personal;
   3. (3) Name of the program;
   4. (4) Agency sponsoring the program;
   5. (5) Date(s) of activity, as well as sites and population served;
   6. (6) A description of the dental hygiene services to be provided; and
   7. (7) The names and license numbers of hygientists working in the program, to be updated whenever changes occur.
2. (b) The form shall be signed and dated by the applicant and the supervising dentist of the program.
3. (c) 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.

Source. #10991, eff 12-9-15