Form 1 dental services form

OMB No. 0915-0151
Expires: July 31, 2011

THE RYAN HIV/AIDS PROGRAM
DENTAL SERVICES REPORT

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 CommunityBased Dental Partnership Program (CBDPP), complete Section 6 instead of Section 5.
SECTION 1. INSTITUTION/PROGRAM AND CONTACT INFORMATION
1. Institution/program information:
Organization

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.

Address

City

Name

ZIP Code

State

Title/Position

□□-□□□□□□□
□□-□□□-□□□□

Address (if different from address in #1)

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

Institution/program Web site address:

City
State

ZIP Code

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

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)

Pager:

(__ __ __) __ __ __-__ __ __ __

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.

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

2010 Dental Services Report

(__ __ __) __ __ __-__ __ __ __

E-mail address:

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

Fax:

1

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

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

Name

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

Title/Position
Address (if different from address in #1)

Name
Title/Position
City

Address (if different from address in #1)

State

ZIP Code

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

(__ __ __) __ __ __-__ __ __ __

Pager:

(__ __ __) __ __ __-__ __ __ __

City
State

E-mail address:

ZIP Code

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

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
HIV-positive, not AIDS
CDC-defined AIDS (HIV-positive with
AIDS-defining illness)
HIV-positive, AIDS status unknown
Total

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?

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Number of
Patients

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

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

Number of
Patients with HIV

Male

12 or younger

Female

13–24

Transgender

25–44

Unknown/unreported

45–64

Total

65 or older

Number of
Patients with HIV

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

Total

Number of
Female Patients
with HIV

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

Pregnant
Not pregnant

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

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

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

Number of
Patients with HIV

Type of Service
Diagnostic

Hispanic or Latino/a
Non-Hispanic or
Latino/a

Preventive
Oral health education/health
promotion

Total

Nutrition counseling

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

Tobacco prevention/cessation
Oral medicine/oral pathology

Race

Number of
Patients with HIV

Restorative

White

Periodontic

Black or African
American

Prosthodontic

Asian

Endodontic

Native Hawaiian or
Other Pacific Islander

Anesthesia/sedation/nitrous
oxide analgesia/palliative care

American Indian or
Alaska Native

Emergency services

More than one race

________________________)

Oral and maxillofacial surgery

Other (specify: ____________

Total

2010 Dental Services Report

Number of
Patients with HIV

3

Number of Visits

16. 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
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

Number of
Patients with HIV

SECTION 3. FUNDING AND PAYMENT COVERAGE
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:

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?

Third Party Payor Coverage

Yes (go to #17b)
No (go to #18)

Number of patients who received
oral health care with NO third
party payor coverage

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
Part A (including Part A MAI)
Part B (including Part B MAI)
Part C
Part D
Special Projects of National
Significance (SPNS)
AIDS Education and Training
Centers (AETCs)

2010 Dental Services Report

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

Amount Received

4

Number of
Patients with HIV

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

i. As part of required curriculum

i. _______

i. _______

i. _______

ii. As part of elective curriculum

ii. _______

ii. _______

ii. _______

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

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.
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ii. ________

SECTION 5. ADDITIONAL DENTAL REIMBURSEMENT PROGRAM INFORMATION

C. NARRATIVES

21. Person authorized to sign for the institution:
Name

24. Site Descriptions

Title/Position

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:

Address (if different from address in #1)

•

City
State

•

ZIP Code

25. Working Relationships with Ryan White HIV/AIDS
Programs

Signature

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.

A. USE OF FUNDING
22. Specify how the Dental Reimbursement Program
funds will be used within your predoctoral
dental/postdoctoral dental/dental hygiene
education program (check all that apply):

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?

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:_________________________)

26. 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.
27. 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.

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

28. 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.

$

23b. Please provide a concise description of the
methods used to calculate the amount reported
in #23a.

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Section 6 should be completed only by CBDPP grantees.
SECTION 6. ADDITIONAL COMMUNITY-BASED DENTAL PARTNERSHIP PROGRAM INFORMATION
29. 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.
Contact Information

Name of Partner
Organization

Does partner
receive
CBDPP
funds?

Brief Description of
Partner’s Role or Function

Street: __________________________________
City: ____________________________________
State: ____________ ZIP: __________________
Phone:__________________________________

Yes †
No

†

Fax:____________________________________
Contact Person:___________________________
Contact Email Address:_____________________
Street: __________________________________
City: ____________________________________
State: ____________ ZIP: __________________
Phone:__________________________________
Fax:____________________________________

Yes †
No

†

Contact Person:___________________________
Contact Email Address:____________________
Street: __________________________________
City: ____________________________________
State: ____________ ZIP: __________________
Phone:__________________________________
Fax:____________________________________

Yes †
No

†

Contact Person:___________________________
Contact Email Address:____________________
Street: __________________________________
City: ____________________________________
State: ____________ ZIP: __________________
Phone:__________________________________
Fax:____________________________________

Yes †
No

†

Contact Person:___________________________
Contact Email Address:____________________
If space for more partners is needed, please copy this page and complete as many boxes as needed.

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30. 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: _________________________________

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