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To ensure compliance with [facility] leave policies.

Annual Leave

[Follow your Facility’s Personnel Policy for leave]

Approval of annual leave for dental personnel will be at the discretion of the supervisor.

Annual leave greater than one hour will have to be applied for in advance. Extended annual leave must be applied for and approved in advance of scheduling patients in the clinic. This will usually require a minimum of three weeks notice of intent to take leave.

Any employee who reports to work after 8:30 a.m. and has failed to call before 8:30 a.m. may be charged with Absent Without Leave (AWOL).

When an employee reports 15 minutes or more late for work it will be charged against their leave record. This may be Annual Leave (AL), Leave Without Pay (LWOP), AWOL or Sick Leave (SL) based upon the circumstances involved in the late reporting.

If an employee has not applied for annual leave and requests leave due to an emergency the following procedure will be used:

Call the clinic and request the leave over the phone, and when possible:

Report to the clinic by 9:00 a.m. and show cause for request of additional leave. If sufficient support staff is present additional leave may be granted.

Complete and sign the SF 71 before going on leave.
Sick Leave


All telephone requests for sick leave will be made before 8:30 a.m. All requests for sick leave will be made to your immediate supervisor.

The supervisor may request a physician's statement, as deemed appropriate. The physician's statement must be in writing stating the physician has examined the employee and found the employee unable to perform their duties.

Sick leave for scheduled appointments must be applied for in advance.

If a written physician's statement is requested and is not furnished when the employee returns to work, the employee may be charged with AWOL for the entire leave in question.
Absent Without Leave (AWOL)

When an employee does not call to request leave or report to the clinic by 8:30 a.m.

When a written physician's statement is requested and not furnished.

Any time an employee is absent from work without approved leave.

When an employee reports 5 15 minutes late for work they will be counted as tardy. If an employee is habitually tardy they will be counseled. If after counseling the employee continues to be tardy they will be charged with AWOL. If after two counseling sessions the employee continues to be tardy a letter of reprimand will be issued or corrective disciplinary action will be proposed.
Leave Without Pay (LWOP)

Leave without pay will be considered on an individual basis within regulatory requirements.


To ensure all employees are appropriately attired to deliver professional services in a safe and efficient manner.
Chairside dental personnel shall wear a full coverage water impervious gown. The gown must be either discarded daily or cleaned if it is not disposable. Gowns must not be worn outside of patient care areas.

Medical scrubs, clean, casual dresses, slacks, shirts, etc. are acceptable; clothing such as jeans, sweatshirts, tank tops are not acceptable when working in patient care areas.

Clean, polished shoes, clinical shoes, or athletic shoes are acceptable. At no time may open toed shoes be worn in patient care areas or dental laboratory.

Finger nails should be smooth and not interfere with wearing gloves necessary for patient care. Rings or other jewelry must be smooth and not interfere with wearing gloves necessary for patient care.

Hair should be clean, groomed and kept neat.

[if applicable]Commissioned Officers shall follow all Local Authority Uniform Instructions when not working in patient care areas.



To solicit patient attitudes and level of satisfaction regarding oral health services provided by [facility]


[Frequency] patients will be asked to complete a Patient Satisfaction survey.

Describe Process.


Patient satisfaction surveys forms will be given to patients who visit the dental clinic in the 1st week of the April and the 1st week of September. Surveys will be distributed to patients as they check in with the instructions to complete the survey and deposit the form in a box at the reception desk.

Attach Patient Satisfaction Form


Results of the patient satisfaction survey will be communicated to facility administration and to each member of the dental staff and. Areas of poor satisfaction will be addressed in a staff meeting, through continuing education, or other appropriate means.

Sample Patient Satisfaction Survey


Please answer the following questions regarding your MOST RECENT visit to the dental clinic.
Date of Visit ________________Provider_________________
Type of Visit Appointment Walk in

(Circle One)

How satisfied were you with:




Length of your dental appointment

Scheduling appointments

Reminder Cards

Staff timeliness

Receiving appropriate dental treatment

Receiving treatment options

Dentist (courteous and professional)

Dental hygienist (courteous and professional)

Dental Assistant (courteous and professional)

Receptionist (courteous and professional)

Quality of dental care provided

Ability to ask questions

Receiving a follow up appointment


Referral policy

Pain control

Overall Dental Care

Compliments or Comments:

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