Form 1 TAB B - DSR Form 2019

Ryan White
HIV/AIDS Program Part F
Dental Services Report

Dental Services Report Form
Release Date: January 2, 2020

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 Office of Management and Budget (OMB) control
number. The OMB control number for this project is 0915-0151, with an expiration date of 6/30/2020. Public
reporting burden for this collection of information is estimated to average 45 hours per response for Ryan White
HIV/AIDS Program (RWHAP) Part F Dental Reimbursement Program respondents and 35 hours per response for
RWHAP Part F Community-Based Dental Partnership Program respondents, 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 14N39,
Rockville, MD 20857.

HIV/AIDS Bureau
Division of Policy and Data
Health Resources and Services Administration
U.S. Department of Health and Human Services
5600 Fishers Lane, Room 9N164
Rockville, MD 20857

This page intentionally left blank.

OMB No. 0915-0151
Expires: June 30, 2020

What’s New In 2020
• The Dental Reimbursement Program (DRP) Notice of Funding Opportunity
(NOFO) release date is January 3, 2020.
• Item 23a. The total unreimbursed costs of oral health care provided to patients
with HIV from July 1, 2018, through June 30, 2019, entered in Item 23a must
match the unreimbursed amount entered in fields 18a and 18g of the SF-424.

DSR Report Deadline
• Community-Based Dental Partnership Programs (CBDPPs) must submit data
no later than 6 p.m. ET, April 3, 2020.
• DRP applicants must submit data no later than 6 p.m. ET, April 3, 2020.

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

All Ryan White HIV/AIDS Program 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
4. Program contact person (dentist or dental
1. Institution/program information:
hygienist) most closely connected to the
Organization
provision of services covered by this Report:
Address
City
State

Zip Code

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

Institution/program website 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)

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:

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



Accredited predoctoral dental education



Accredited postdoctoral dental education



Accredited dental hygiene education program

program—School of Dentistry

program—School of Dentistry, Hospital, Health
Center, or Other

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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 Report:

Note: 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 your program’s students, residents,
faculty, and other dental staff:

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

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?

2020 Dental Services Report

Number of
Patients

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

2

9a. Of the number of patients with HIV reported in
#7a, indicate the number by gender:
Gender

Number of
Patients with HIV

Male

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

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 patients at birth:
Sex at Birth

Number of
Patients with HIV

Male
Female

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

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

2020 Dental Services Report

Number of
Patients with HIV

Number of
Patients with HIV

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
Asian Indian
Chinese
Filipino

Number of Patients
with HIV

Japanese
Korean
Vietnamese
Other Asian
Total

3

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 Number of Patients
Islander Race
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

15. 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
Emergency services

45–64

Other (specify:

65 or older

_______________________ )

Unknown/unreported
Total
14. Of the number of patients with HIV reported in
#7a, indicate the number by household income:
Income
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

Number of
Patients with HIV

16. 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:
Location of Primary
Number of
Medical
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

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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)

Payment Source

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

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):

Amount Received

Part A (including Part A MAI)
Part B (including Part B MAI)
Part C
Part D

Number of
Patients with
HIV

Total
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

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

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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 nonstudent 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 you provide below.
Predoctoral
Dental
Students

Dental
Residents or
Postdoctoral
Students

i. As part of required curriculum

i.

i.

i.

ii. As part of elective curriculum

ii.

ii.

ii.

Dental
Hygiene
Students

Other
Nonstudent
Dental
Providers

a. The total number of students and residents who
were enrolled in all years of your school or
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
ii.

e. The total number of hours that all students,
residents, and other providers spent providing direct
clinical services for patients with HIV
If you are applying for DRP funding, continue with Section 5. If you are submitting
an annual CBDPP data report, skip to Section 6.

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SECT ION 5. ADDITIONAL DENTAL REIMBURSEMENT PROGRAM INFORMATION

C. NARRATIVES

21. Person authorized to sign for the institution:
Name
Title/position
Address (if different from address in #1)

Note: A text box is available in the Database
Utility for narrative responses (Items 24-26).
24. Site Descriptions

City
State
Signature

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:

Zip Code

A. USE OF FUNDING

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

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:

• Are such facilities organizational components of
your institution, or are they separate
organizations?
25. Working Relationships with Ryan White HIV/AIDS
Programs

)

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.

2020 Dental Services Report

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). Include 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.

7

Section 6 should be completed only by CBDPP recipients.
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 functions in the partnership.
Name of Partner Contact Information
Organization

Does Partner
Receive
CBDPP
Funds?

Brief Description of
Partner’s Role or Function

Street:
City:
State:

ZIP:

Phone:

Yes

Fax:

No




Contact person:
Contact email address:
Street:
City:
State:

ZIP:

Phone:

Yes
No

Fax:




Contact person:
Contact email address:
Street:
City:
State:

ZIP:

Phone:

Yes
No

Fax:




Contact person:
Contact email address:
Street:
City:
State:
Phone:
Fax:

ZIP:

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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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
Runaway 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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