Instructions for Form A "Daily Fluoridation Report" - Massachusetts

This document contains official instructions for Form A, Daily Fluoridation Report - a form released and collected by the Massachusetts Department of Public Health.

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Massachusetts Department of Public Health
Daily Fluoridation Report- Form A
Purpose: This form is to be used by the public water system (PWS) to document finished water
fluoride concentrations from treatment plants. All pumping fluoridated source MUST be tested
daily for fluoride at the entry point to the distribution system or after the point of fluoride
application.
The Center of Disease Control has recommended an optimum fluoride level of 0.7 ppm.
Directions:
1. Use the same form daily for one month for each source or manifold or combined sources.
Enter the monitoring period in month/year format.
2. Section I: PWS Information
Enter 1. The system name; 2. 7-digit MassDEP assigned Public Water System
identification number; 3. City, Town or District; 4. MassDEP Source Code(s) and
Location ID/Name; and 5. If the sources are manifold, list the source/combined sources.
3. Section II: PWS Chemical Use Information
1. Check the type of fluoride used
2. List the purity of the fluoride chemical used
3. Check if the fluoride-metering pumps are protected by two (2) operating anti-siphoning
(back pressure) valves
4. List the date that the anti-siphon valves were disassembled and inspected in the last 12
months
5. Check if the fluoride test meter was calibrated each day before use
6. List if you need technical assistance and briefly describe the problem. Use additional
paper if necessary.
If you are using the excel version of the daily fluoridation report, follow the instructions
below:
a. Left double-click anywhere in the table. This will open up an excel table
embedded within the Microsoft Word document.
b. The table is presented in its entirety within the allocated space, therefore you
should not have to use the scrollbars of the excel table. If you do use these
scrollbars, make sure to return the vertical and horizontal scrollbars to the
left-most and top-most positions, respectively, once you have finished
entering data.
c. After you finish entering data into the table, left click anywhere outside of the
table in the main document. This will close the excel table and you will return
to the main Microsoft Word document.
Note: If you notice that some of the data is not visible, i.e. part of the table is cut-off,
return to the excel table by left double-clicking anywhere in the table and move the
horizontal and vertical scrollbars to their left-most and top-most positions,
respectively.
4. Section III: Daily Result for each day fluoride is added to the water supply
1. Gallons of Water Produced: Enter the number of gallons produced to the nearest
1,000 gallons.
2. Fluoride Chemicals Added in Pounds: Enter each day’s quantity of fluoride
Compound applied to the nearest tenth of a gallon or nearest pound.
Massachusetts Department of Public Health
Daily Fluoridation Report- Form A
Purpose: This form is to be used by the public water system (PWS) to document finished water
fluoride concentrations from treatment plants. All pumping fluoridated source MUST be tested
daily for fluoride at the entry point to the distribution system or after the point of fluoride
application.
The Center of Disease Control has recommended an optimum fluoride level of 0.7 ppm.
Directions:
1. Use the same form daily for one month for each source or manifold or combined sources.
Enter the monitoring period in month/year format.
2. Section I: PWS Information
Enter 1. The system name; 2. 7-digit MassDEP assigned Public Water System
identification number; 3. City, Town or District; 4. MassDEP Source Code(s) and
Location ID/Name; and 5. If the sources are manifold, list the source/combined sources.
3. Section II: PWS Chemical Use Information
1. Check the type of fluoride used
2. List the purity of the fluoride chemical used
3. Check if the fluoride-metering pumps are protected by two (2) operating anti-siphoning
(back pressure) valves
4. List the date that the anti-siphon valves were disassembled and inspected in the last 12
months
5. Check if the fluoride test meter was calibrated each day before use
6. List if you need technical assistance and briefly describe the problem. Use additional
paper if necessary.
If you are using the excel version of the daily fluoridation report, follow the instructions
below:
a. Left double-click anywhere in the table. This will open up an excel table
embedded within the Microsoft Word document.
b. The table is presented in its entirety within the allocated space, therefore you
should not have to use the scrollbars of the excel table. If you do use these
scrollbars, make sure to return the vertical and horizontal scrollbars to the
left-most and top-most positions, respectively, once you have finished
entering data.
c. After you finish entering data into the table, left click anywhere outside of the
table in the main document. This will close the excel table and you will return
to the main Microsoft Word document.
Note: If you notice that some of the data is not visible, i.e. part of the table is cut-off,
return to the excel table by left double-clicking anywhere in the table and move the
horizontal and vertical scrollbars to their left-most and top-most positions,
respectively.
4. Section III: Daily Result for each day fluoride is added to the water supply
1. Gallons of Water Produced: Enter the number of gallons produced to the nearest
1,000 gallons.
2. Fluoride Chemicals Added in Pounds: Enter each day’s quantity of fluoride
Compound applied to the nearest tenth of a gallon or nearest pound.
3. Amount of Make-up Water used by Sodium Fluoride Saturator: For PWS using
NaF, enter the amount of water used by the NaF saturator in gallons or cubic feet.
4. Results of Fluoride Test: For each day of the month enter the average fluoride
concentration in milligrams/liter (ppm).
5. Name of Tester and Comments: Each day enter the name of the operator who is
testing the fluoride levels and or comments (ex. Well off-line - no testing).
5. The last day of each month the Certified Operator or responsible person must:
Total all daily numbers and then calculate monthly average; and 2. Enter their
1.
name, sign and date the form; and 3. Complete the PWS contact information.
** Form A, B, and C must be returned to the Massachusetts Department of Public
th
Health Office of Oral Health by the 10
day following the reporting month
Form A may also be used to comply with MassDEP’s monthly treatment chemical report
requirement 310 CMR 22.15(4). If you intend to use this form for compliance with MassDEP
requirements you must submit another copy of Form A to your MassDEP regional office.
Form A is also available in an Excel format to allow for electronic tabulation of totals and averages.
To get a copy of the Excel form please contact DPH Office of Oral Health at 617-624-5573
For Electronic copies of all please contact Heather Benabbou at: Heather.Benabbou@state.ma.us forms , DPH Office
of Oral Health and MassDEP/DWP at:http://www.mass.gov/eea/agencies/massdep/service/approvals/fluoride.html
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