1 Ryan White HIV/AIDS Program Dental Services Report

Ryan White HIV/AIDS Program Part F Dental Services Report

B - 2015 DSR Form

Ryan White HIV/AIDS Program Dental Services Report.

OMB: 0915-0151

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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

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Shape1 Please refer to the Dental Services Report Instructions for a description of each section and item.

Shape2

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

  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:



  1. 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)


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


Accredited predoctoral dental education programSchool of Dentistry

Accredited postdoctoral dental education programSchool of Dentistry, Hospital, Health Center or Other

Accredited dental hygiene education program





  1. Shape3 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:



  1. 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:









  1. Shape4 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

Shape5

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 Unknowncategory whenever possible.



7a. Total number of unduplicated patients with HIV treated by students, residents, faculty, and other dental staff of your program:


  1. Please show the HIV/AIDS status of the patients reported in #7a (as of the first visit in the period covered by this Report):

Shape6





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?


Shape7

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



  1. 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



  1. 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



  1. 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


    Of the number of patients with HIV reported in #7a, 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


  1. 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:

)






















  1. 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)



  1. 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














  1. 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


  1. 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


Shape8 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.

Shape9 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

Partners 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:























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