OMB No. 0915-0151
Expires: XX/XX/201X
THE
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 currently valid OMB control number. The OMB control number for this project is 0915-0151. Public reporting burden for this collection of information is estimated to average 35-45 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-49, Rockville, MD 20857.
Division
of
Community
HIV/AIDS
Programs
HIV/AIDS Bureau
Health Resources and Services Administration
Parklawn Building, Room 9-74
5600 Fishers Lane
Rockville, Maryland 20857
This page intentionally left blank.
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.
SECT ION 1. INSTITUTION/PROGRAM AND CONTACT INFORMAT ION
Institution/program information:
Organization
Address
City
State Zip Code
Nine-digit Federal tax ID # □ □ - □ □ □ □ □ □ □
D-U-N-S number: □ □ - □ □ □ - □ □ □ □
Institution/program Web site address:
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)
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
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: (__ __ __) __ __ __ - __ __ __ __
Email address:
Program contact person (dentist or dental hygienist) most closely connected to the provision of services covered by this Report:
Name
Title/Position
Address (if different from address in #1)
City
State Zip Code
Telephone: (__ __ __) __ __ __ - __ __ __ __
Fax: (__ __ __) __ __ __ - __ __ __ __
Pager: (__ __ __) __ __ __ - __ __ __ __
Email address:
Contact
person (if
different from #4)
responsible for verifying and submitting data contained in this
Dental Services this
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
Telephone: (__ __ __) __ __ __ - __ __ __ __
Fax: (__ __ __) __ __ __ - __ __ __ __
Pager: (__ __ __) __ __ __ - __ __ __ __
Email address:
SECT ION 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.
7a. Total number of unduplicated patients with HIV treated by students, residents, faculty, and other dental staff of your program:
Please show the HIV/AIDS status of the patients reported in #7a (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
7b. Of the number of patients reported in #7a, how
many were seen by your program for the first time
during the period covered by this Report?
9a. Of the number of patients with HIV reported in
#7a, indicate the number by gender:
Gender |
Number of Patients with HIV |
Male |
|
Female |
|
Transgender |
|
Unknown/unreported |
|
Total |
|
9b. Of the number of patients with HIV reported in
#7a, indicate the number by the sex assigned to the clients at birth:
Sex at Birth |
Number of Patients with HIV |
Male |
|
Female |
|
Total |
|
Of the number of female patients with HIV reported in #9b, indicate the number by pregnancy status:
Pregnancy Status |
Number of Female Patients with HIV |
Pregnant |
|
Not pregnant |
|
Unsure if pregnant |
|
Unknown/unreported |
|
Total |
|
11a. Of the number of patients with HIV reported in
#7a, indicate the number by ethnicity:
Ethnicity |
Number of Patients with HIV |
Hispanic or Latino/a
|
|
Non-Hispanic or Latino/a |
|
Total |
|
11b. Of the number of Hispanic patients with HIV reported
in #11a, indicate the number by ethnic group. The total number reported here must equal the number of Hispanic or Latino/a patients reported in #11a:
Ethnicity |
Number of Patients with HIV |
Mexican, Mexican American, Chicano/a |
|
Puerto Rican |
|
Cuban |
|
Other Hispanic, Latino/a or Spanish origin |
|
Total |
|
12a. Of the number of patients with HIV reported in #7a,
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 |
|
12b. Of the number of Asian patients with HIV reported in
#12a, indicate the number by racial group. The total number reported here must equal the number of Asian patients reported in #12a:
Asian Race |
Number of Patients with HIV |
Asian Indian |
|
Chinese |
|
Filipino
|
|
Japanese |
|
Korean |
|
Vietnamese |
|
Other Asian |
|
Total |
|
12c. Of the number of Native Hawaiian or other
Pacific Islander patients with HIV reported in
#12a, indicate the number by racial group. The
total number reported here must equal the
number of Native Hawaiian or other Pacific
Islander patients reported in #12a:
Native Hawaiian/Pacific Islander Race |
Number of Patients with HIV |
Native Hawaiian |
|
Guamanian or Chamorro |
|
Samoan
|
|
Other Pacific Islander |
|
Total |
|
Of the number of patients with HIV reported in #7a, 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 |
|
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 |
|
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 |
|
Indicate the total number of visits made by patients reported in #7a for each type of the following 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 |
|
Emergency services |
|
Other (specify: ) |
|
Of the number of patients with HIV reported in #7a, please show where they received their primary medical care by each of the following locations:
SECT ION 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 (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) |
|
Of the number of patients reported in #7a, 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 |
|
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 |
|
|
SECT ION 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 |
i.
ii. |
i.
ii. |
i.
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. |
|
SECT ION 5. ADDITIONAL DENTAL REIMBURSEMENT PROGRAM INFORMATION
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
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):
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):
$
23b. 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?
25. 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.
26. 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.
SECT
ION
6.
ADDITIONAL
COMMUNITY-BASED
DENTAL
PARTNERSHIP
PROGRAM
INFORMATION
27. 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.
28. 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:
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Jones, Andrew |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |