Instructions for DPH Fluoride Form A "Daily Fluoridation Report Form" - Massachusetts

This document contains official instructions for DPH Fluoride Form A, Daily Fluoridation Report Form - a form released and collected by the Massachusetts Department of Environmental Protection. An up-to-date fillable DPH Fluoride Form A is available for download through this link.

Instruction Details:

  • This 1-page document is available for download in PDF;
  • Actual and applicable for the current year;
  • Complete, printable, and free.

Download your copy of the instructions by clicking the link below or browse hundreds of other forms in our library of forms released by the Massachusetts Department of Environmental Protection.

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Download Instructions for DPH Fluoride Form A "Daily Fluoridation Report Form" - Massachusetts

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Instructions for Daily Fluoridation Report (Excel format)
This report is designed for the Microsoft Excel user. Data may be entered directly into the fields
provided. For each Yes/No question, an “X” may be entered into the field.
Notes:
1.) The user must select the “Type of fluoride chemical used” (Section II, No. 1) by entering an
“X” in the box adjacent to the chemical used. The fluoride ion dosage will not calculate if the
user fails to select a chemical.
2.) If the user selects more than one chemical, the fluoride ion dosage will be calculated based on
the first chemical selected.
3.) If the user selects an incorrect chemical, the fluoride ion dosage will be incorrectly calculated.
4.) The percent purity of the fluoride chemicals must be accurately entered for the fluoride ion
dosage to be calculated. For sodium fluoride use 98%. For sodium silico-fluoride (Na
SiF
) use
2
6
98-99 %. For hydrofluosilicic acid (H
SiF
) use 23 – 30 %, as required by your delivered
2
6
chemical strength.
th
5.) The dosage values in the 5
column under “Calculated Fluoride Ion Dosage (ppm)” and as
calculated in the field labeled “If you use a saturator: calculate monthly Fluoride Ion Dosage”
are adjusted by a value of +0.1 ppm to account for an average natural fluoride concentration in
our source waters.
6.) If no water (zero gallons of treated water) is pumped during any day, the fields for that day
th
must be left blank as shown in the examples on the 25
of the month.
MassDEP and Mass DPH hereby acknowledge Mr. Lawrence E. Guilmartin of H
0 Software
2
of Groton for voluntarily contributing this reporting form for the convenience of
Massachusetts' public water systems.
Instructions for Daily Fluoridation Report (Excel format)
This report is designed for the Microsoft Excel user. Data may be entered directly into the fields
provided. For each Yes/No question, an “X” may be entered into the field.
Notes:
1.) The user must select the “Type of fluoride chemical used” (Section II, No. 1) by entering an
“X” in the box adjacent to the chemical used. The fluoride ion dosage will not calculate if the
user fails to select a chemical.
2.) If the user selects more than one chemical, the fluoride ion dosage will be calculated based on
the first chemical selected.
3.) If the user selects an incorrect chemical, the fluoride ion dosage will be incorrectly calculated.
4.) The percent purity of the fluoride chemicals must be accurately entered for the fluoride ion
dosage to be calculated. For sodium fluoride use 98%. For sodium silico-fluoride (Na
SiF
) use
2
6
98-99 %. For hydrofluosilicic acid (H
SiF
) use 23 – 30 %, as required by your delivered
2
6
chemical strength.
th
5.) The dosage values in the 5
column under “Calculated Fluoride Ion Dosage (ppm)” and as
calculated in the field labeled “If you use a saturator: calculate monthly Fluoride Ion Dosage”
are adjusted by a value of +0.1 ppm to account for an average natural fluoride concentration in
our source waters.
6.) If no water (zero gallons of treated water) is pumped during any day, the fields for that day
th
must be left blank as shown in the examples on the 25
of the month.
MassDEP and Mass DPH hereby acknowledge Mr. Lawrence E. Guilmartin of H
0 Software
2
of Groton for voluntarily contributing this reporting form for the convenience of
Massachusetts' public water systems.