ANNUAL HEAD START TRACKING FORM
FOR ORAL HEALTH ACTIVITIES
Your name: _______________________________ (use separate page if listing names)
Head Start Program: _______________________ County/City _____________
Date of services provided: ____________________
Total # of dental providers present:________
This form will assist in tracking oral health services provided to Virginia Head Start programs.
PLEASE COMPLETE AND RETURN TO SUSAN PHARR
FAX #: 804-864-7783
| Service | # of contact hours* | # of participants |
| Dental Exams (dentist) |
||
| Dental Screenings (hygienist) |
||
| Fluoride Varnish | ||
| Staff Education | ||
| Parent Education | ||
| Classroom Education | ||
| Health Advisory Committee | ||
| Health/Resource Fairs | ||
| Other |
* Contact hours = # hours spent providing service (not including preparation)
Sat, Jan 9, 2010
Head Start