Form dental 1 dental 1 dental

OMB No. 0915-0151

Expires: June 30, 2008

T HE RYAN HIV/AIDS PROGRAM

DENTAL SERVICES REPORT

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0915-0151. Public reporting burden for this collection of information is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to: HRSA Clearance Officer, Room 10-33, 5600 Fishers Lane, Rockville, MD., 20857.

Division of Community-Based Programs

HIV/AIDS Bureau

Health Resources and Services Administration

Parklawn Building, Room 7A-30

5600 Fishers Lane

Rockville, Maryland 20857

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Please refer to the Dental Services Report Instructions for a description of each section and item.

All Part F Dental programs must complete Sections 1 through 4. If you are applying for Dental Reimbursement Program (DRP) funding, continue to Section 5. If you are submitting the annual data report for the Community-Based Dental Partnership Program (CBDPP), complete Section 6 instead of Section 5.

Section 1. Institution/Program and Contact Information

1. Institution/program information:

Organization

Address

City

State ZIP Code

Nine-digit Federal tax ID # □ □ - □ □ □ □ □ □ □ D-U-N-S number: □ □ - □ □ □- □ □ □ □

Institution/program Web site address:

2. Is the institution in #1 using this Report to (select only one):
   
   

 Apply for funds through the Dental Reimbursement Program (DRP)? (Complete Sections 1 through 5)

• Submit data for the Community-Based Dental Partnership Program (CBDPP)? (Complete Sections 1 through 4 and 6)
  
  

3. Type of institution/program submitting this Report (select only one):
   
   

 Accredited predoctoral dental education program—School of Dentistry

 Accredited postdoctoral dental education program—School of Dentistry, Hospital, Health Center or Other

• Accredited dental hygiene education program
  
  
  

4. Program contact person (dentist or dental hygienist) most closely connected to the provision of services covered by this Report:

Program Contact Person: This individual will be notified of funding and will be considered the primary contact person for all Dental Program communications.

Name

Title/Position

Address (if different from address in #1)

City

State ZIP Code

Telephone: (__ __ __) __ __ __-__ __ __ __

Fax: (__ __ __) __ __ __-__ __ __ __

Pager: (__ __ __) __ __ __-__ __ __ __

E-mail address:

5.  Check this box if the program contact person in #4 would like to receive bimonthly updates from the HIV/AIDS Bureau on technical assistance and primary care related to the Ryan White HIV/AIDS Program.

Bimonthly updates are distributed by email ONLY; therefore, you must specify an e-mail address in #4.

6. Alternate program contact person (this individual will be contacted if the person identified in #4 cannot be reached):

Name

Title/Position

Address (if different from address in #1)

City

State ZIP Code

Telephone: (__ __ __) __ __ __-__ __ __ __

Fax: (__ __ __) __ __ __-__ __ __ __

Pager: (__ __ __) __ __ __-__ __ __ __

E-mail address:

7. Contact person (if different from #4) responsible for verifying and submitting data contained in this Dental Services Report:

The data you provide in this Report, as part of your
Federally-supported program, are subject to audit.

Name

Title/Position

Address (if different from address in #1)

City

State ZIP Code

T elephone: (__ __ __) __ __ __-__ __ __ __

Fax: (__ __ __) __ __ __-__ __ __ __

Pager: (__ __ __) __ __ __-__ __ __ __

E-mail address:

Section 2. Patient Demographics AND ORAL HEALTH SERVICES

Note: Throughout this Report, all references to “your program” refer to aggregate data from your institution/program including all your partners or sites, if applicable. Avoid reporting in the “Unknown” category whenever possible.

8a. Total number of unduplicated patients with HIV treated by students, residents, faculty, and other dental staff of your program:

8b. Of the number of patients reported in #8a, how many were seen by your program for the first time during the period covered by this Report?

9. Please show the HIV/AIDS status of the patients reported in #8a (as of the first visit in the period covered by this Report):
   
   

HIV/AIDS Status	Number of Patients
HIV-positive, not AIDS
CDC-defined AIDS (HIV-positive with AIDS-defining illness)
HIV-positive, AIDS status unknown
Total

10. Of the number of patients reported in #8a, indicate the number by gender:

    Gender	Number of Patients with HIV
    Male
    Female
    Transgender
    Unknown/unreported
    Total

11. Of the number of female patients with HIV reported in #10, indicate the number by pregnancy status:

Pregnancy Status	Number of Female Patients with HIV
Pregnant
Not pregnant
Unsure if pregnant
Unknown/unreported
Total

If unknown/unreported, explain why: ____________

_________________________________________

12a. Of the number of patients reported in #8a, indicate the number by ethnicity:

Ethnicity	Number of Patients with HIV
Hispanic or Latino/a
Non-Hispanic or Latino/a
Total

12b. Of the number of patients reported in #8a, indicate the number by race:

Race	Number of Patients with HIV
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
More than one race
Total

13. Of the number of patients reported in #8a, indicate the number by age:

Age	Number of Patients with HIV
12 or younger
13–24
25–44
45–64
65 or older
Unknown/unreported
Total

13. Of the number of patients reported in #8a, indicate the number by household income:
    
    

    Income	Number of Patients with HIV
    Equal to or below the Federal poverty line
    101–200% of Federal poverty line
    201–300% of Federal poverty line
    > 300% of Federal poverty line
    Unknown/unreported
    Total

14. Indicate the total number of visits made by patients reported in #8a for each type of oral health service:

Type of Service	Number of Visits
Diagnostic
Preventive
Oral health education/health promotion
Nutrition counseling
Tobacco prevention/cessation
Oral medicine/oral pathology
Restorative
Periodontic
Prosthodontic
Oral and maxillofacial surgery
Endodontic
Anesthesia/sedation/nitrous oxide analgesia/palliative care
Emerg0ency services
Other (specify: ____________ ________________________)

13. Of the number of patients reported in #8a, please show where they received their primary medical care by each of the following locations:
    
    

Location of Primary Medical Care	Number of Patients with HIV
Provider or clinic co-located in the same physical facility or site where oral health care is provided
Provider or clinic in the same institution providing oral health care, but at a different site
Other medical provider or clinic not in the same institution providing oral health care, at a different site
Unknown/unreported
Total

SECTION 3. FUNDING and PAYMENT COVERAGE

17a. Did the parent institution of the program identified in #1 receive any other Ryan White HIV/AIDS Program funding (not only for oral health care or training) during the period covered by this Report?

 Yes (go to #17b)

 No (go to #18)

17b. Indicate the total funds the parent institution of the program identified in #1 received from other Ryan White HIV/AIDS Program grants to provide any HIV-related services or training during the period covered by this Report (rounded to the nearest dollar):

Ryan White Program Part	Amount Received
Part A
Part B
Part C
Part D
Special Projects of National Significance (SPNS)
AIDS Education and Training Centers (AETCs)

18. Of the number of patients reported in #8a, indicate the number whose third party coverage for oral health services fell under each of the following categories:
    
    

Third Party Payor Coverage	Number of Patients with HIV
Number of patients who received oral health care with NO third party payor coverage
Number of patients who received oral health care with PARTIAL third party payor coverage
Number of patients whose third party payor coverage status was UNKNOWN

19. Indicate the number of patients with HIV whose oral health care was partially covered by each of the following sources and the total amount of payment received (rounded to the nearest dollar):
    
    

Payment Source	Number of Patients with HIV	Payment Received ($)
Medicaid (non-HMO/ non‑managed care)
Medicaid (HMO/managed care)
Medicare
Other public insurance (e.g., TRICARE, VA)
Private insurance, including HMO/managed care
Self-pay or cash
Other (specify: ________ ___________________)
Unknown

Section 4. Staffing and Training

20. For the period covered by this Report, provide the following information about the number of dental students, residents, dental hygiene students, and other non-student dental providers who participated in or rotated through your program. Please feel free to attach an optional narrative description of your HIV training program as further clarification of the information that you provide below.
    
    

	Predoctoral Dental Students	Dental Residents or Postdoctoral Students	Dental Hygiene Students	Other Non-Student Dental Providers
a. The total number of students and residents who were enrolled in all years of your school or program
b. The total number of students, residents, and other providers who received formal didactic instruction in medical assessment or oral health management for patients with HIV
c. The total number of students, residents, and other providers who gained experience providing direct clinical services for patients with HIV
d. The total number of hours of your training curriculum (didactic and clinical combined) that were dedicated to issues related to medical assessment or oral health management for patients with HIV i. As part of required curriculum	_______	_______	_______
ii. As part of elective curriculum	ii. _______	ii. _______	ii. _______	ii. ________
e. The total number of hours that all students, residents, and other providers spent providing direct clinical services for patients with HIV

Continue with Section 5 if you are applying for DRP funding. Otherwise, skip to Section 6 if you are submitting an annual CBDPP data report.

Section 5. ADDITIONAL Dental Reimbursement Program Information

20. Person authorized to sign for the institution:

Name

Title/Position

Address (if different from address in #1)

City

State ZIP Code

Signature

A. Use of Funding

20. Specify how the Dental Reimbursement funds will be used within your predoctoral dental/postdoctoral dental/dental hygiene education program (check all that apply):

 Direct patient services (e.g., provider/faculty salaries)

 Patient education or outreach

 Curriculum development

 Student education/training

 Staff education/training

 Clinic staff salary/support

 Equipment/instruments/supplies/materials

• Pharmaceuticals or dental medicaments

• General operations

• Other (specify:_________________________)

B. UnreimburseD COSTS

23a. Total unreimbursed costs of oral health care provided to patients with HIV (rounded to the nearest dollar):

$

Submit responses to #23b through #28 as
separate attachments.

23b. As a separate attachment, please provide a concise description of the methods used to calculate the amount reported in #23a.

C. NarrativeS

24. Site Descriptions

List and concisely describe the sites where your predoctoral dental/postdoctoral dental/dental hygiene education program provides oral health services to patients with HIV. In identifying these sites, please address the following questions:

• Do your students or residents provide direct patient care in community-based facilities?

• Are such facilities organizational components of your institution, or are they separate organizations?

24. Working Relationships with Ryan White HIV/AIDS Programs

Concisely describe working relationships that your predoctoral dental/postdoctoral dental/dental hygiene education program has established with the Ryan White HIV/AIDS Programs listed in item #17b, including Part A HIV Planning Councils and Part B HIV Consortia. Describe how your program has been working to maximize coordination, integration, and effective linkages among local Ryan White HIV/AIDS Programs.

24. Development of the Statewide Coordinated Statement of Need

Concisely describe how your predoctoral dental/postdoctoral dental/dental hygiene education program has been involved in the development and updating of the Statewide Coordinated Statement of Need (SCSN) in your state.

24. Outreach

Concisely describe any additional ways your predoctoral dental/postdoctoral dental/dental hygiene education program conducts outreach to persons with HIV to increase their awareness of the availability of oral health services, or builds community links with program managers and providers working with this population.

24. Special Strengths or Unique Capabilities

Concisely describe any special strengths or unique capabilities of your predoctoral dental/postdoctoral dental/dental hygiene education program in providing oral health care for patients with HIV (e.g., facilities, hours of operation, support services, or staff skills or expertise). Responses might include information regarding evening and weekend clinic hours, onsite participation in clinical trials, provider or staff diversity, special patient education programs, the availability of childcare services, language translation services, transportation services, or other special strengths.

Section 6 should be completed only by CBDPP grantees.

Section 6. ADDITIONAL Community-Based Dental Partnership Program Information

24. List the names and addresses of the member organizations of your Community-Based Dental Partnership Program (other than your institution) and their roles or function in the partnership.

Name of Partner Organization	Contact Information	Does partner receive CBDPP funds?	Brief Description of Partner’s Role or Function
	Street: __________________________________ City: ____________________________________ State: ____________, ZIP __________________ Phone:__________________________________ Fax:____________________________________ Contact Person___________________________ Contact Email Address:_____________________	Yes  No 
	Street: __________________________________ City: ____________________________________ State: ____________, ZIP __________________ Phone:__________________________________ Fax:____________________________________ Contact Person___________________________ Contact Email Address:____________________	Yes  No 
	Street: __________________________________ City: ____________________________________ State: ____________, ZIP __________________ Phone:__________________________________ Fax:____________________________________ Contact Person___________________________ Contact Email Address:____________________	Yes  No 
	Street: __________________________________ City: ____________________________________ State: ____________, ZIP __________________ Phone:__________________________________ Fax:____________________________________ Contact Person___________________________ Contact Email Address:____________________	Yes  No 

If space for more partners is needed, please copy this page and complete as many boxes as needed.

24. Indicate which of the following populations were specially targeted to receive services through the
    Community-Based Partnership Program (check all that apply):

 Urban populations

 Suburban populations

 Rural populations other than migrant or seasonal workers

 Migrant or seasonal workers

 Runaway or street youth

 Gay, lesbian, bisexual, transgender youth

 Gay, lesbian, bisexual, transgender adults

 Homeless persons

 Incarcerated persons

 Paroled persons

 Substance addicted persons

 Other, specify: _________________________________