Form B - 2017 DSR Form

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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_{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}

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

Email address:

5. 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:

6. 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:

8. 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

10. 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

13. 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

14. 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

14. 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: )

14. 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)

18. 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

18. 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}

21. 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: