Form IOCI18-384 "Annual Report of Public Health Dental Hygienist Services and Location of Work" - Illinois

What Is Form IOCI18-384?

This is a legal form that was released by the Illinois Department of Public Health - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Illinois Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form IOCI18-384 by clicking the link below or browse more documents and templates provided by the Illinois Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form IOCI18-384 "Annual Report of Public Health Dental Hygienist Services and Location of Work" - Illinois

1097 times
Rate (4.5 / 5) 55 votes
Annual Report of Public Health Dental Hygienist Services and Location of Work
As required in the Illinois Public Act 099-0680, the public health dental hygienist who has rendered services under public health
supervision must provide an annual report of activity to the Division of Oral Health in the Illinois Department of Public Health.
REMINDER: Annual completion of four hours of continuation education in public health dentistry is required per Illinois Public
Act 099 0680.
PUBLIC HEALTH DENTAL HYGIENIST INFORMATION
Name
IL Dental Hygiene
(Last, First, Middle)
License #
Address
City
State
ZIP Code
Telephone
E-mail Address
SUPERVISING/SPONSORING DENTIST INFORMATION
Name
IL Dental
License #
(Last, First, Middle)
Address
City
State
ZIP Code
Telephone
E-mail Address
Initiation date of written supervision agreement with public health dental hygienist
LOCATION AND SERVICES PROVIDED BY PUBLIC HEALTH DENTAL HYGIENIST
Estimated number of people served
in each age group
Reporting Calendar Year:
Type of Public Health Setting
County
Federally Qualified Health Center
State Operated Facility
Other State Licensed Facility
Local Public Health Department
Head Start / Early Head Start
Women, Infant, and Children (WIC) Facility
Illinois Certified School-Based Health Center
School-Based Oral Health Program
Other (List)
Other (List)
CERTIFICATION: I herein certify that this Annual Report of Public Health Dental Hygienist Services and Location of Work and the
information herein are true and accurate.
Signature of Public Health Hygienist:
Date:
Signature of Supervising/Sponsoring Dentist:
Date:
Please email complete signed forms to
DPH.PHDentalHygienist@illinois.gov
by January 31st for the previous calendar year.
Printed by Authority of the State of Illinois
P.O. #3518786
250
1/18
IOCI 18-384
Annual Report of Public Health Dental Hygienist Services and Location of Work
As required in the Illinois Public Act 099-0680, the public health dental hygienist who has rendered services under public health
supervision must provide an annual report of activity to the Division of Oral Health in the Illinois Department of Public Health.
REMINDER: Annual completion of four hours of continuation education in public health dentistry is required per Illinois Public
Act 099 0680.
PUBLIC HEALTH DENTAL HYGIENIST INFORMATION
Name
IL Dental Hygiene
(Last, First, Middle)
License #
Address
City
State
ZIP Code
Telephone
E-mail Address
SUPERVISING/SPONSORING DENTIST INFORMATION
Name
IL Dental
License #
(Last, First, Middle)
Address
City
State
ZIP Code
Telephone
E-mail Address
Initiation date of written supervision agreement with public health dental hygienist
LOCATION AND SERVICES PROVIDED BY PUBLIC HEALTH DENTAL HYGIENIST
Estimated number of people served
in each age group
Reporting Calendar Year:
Type of Public Health Setting
County
Federally Qualified Health Center
State Operated Facility
Other State Licensed Facility
Local Public Health Department
Head Start / Early Head Start
Women, Infant, and Children (WIC) Facility
Illinois Certified School-Based Health Center
School-Based Oral Health Program
Other (List)
Other (List)
CERTIFICATION: I herein certify that this Annual Report of Public Health Dental Hygienist Services and Location of Work and the
information herein are true and accurate.
Signature of Public Health Hygienist:
Date:
Signature of Supervising/Sponsoring Dentist:
Date:
Please email complete signed forms to
DPH.PHDentalHygienist@illinois.gov
by January 31st for the previous calendar year.
Printed by Authority of the State of Illinois
P.O. #3518786
250
1/18
IOCI 18-384