0920-20PM Screening FORM

Oral health screening fields form

Sample Oral Health Screening Form for School Children

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx

Information obtained by the screener on the day of the screening
Screen Date: / /	School Code:	Screeners Initials:
SSID:		Grade*:
Untreated Decay: No Yes	Treated Decay: No Yes	Dental Sealants: No Yes
Treatment Urgency: None Early Urgent
Sources to obtain demographic information: From the school: include the demographic information below on the screening form. From the Department of Education: make sure to include SSID on the screening form. Use the demographic information section below as a guide for collecting the corresponding variables and their categories. From the parent or guardian questionnaire: staple the questionnaire to the screening form. Refer to sample questionnaire on page 53 of the Basic Screening Survey manual.
Sex: Female Male	Date of Birth: / / or Age (Years):      	NSLP: Not Eligible Eligible
Hispanic or Latino: No Yes
Race (check all that apply): American Indian/Alaska Native Black/African American Native Hawaiian/Other Pacific Islander Asian White

NOTE: ASTDD recommends that you use official data from the Department of Education or schools as a primary source for demographics and the parent or guardian consent form or questionnaire secondarily.

* Grade is collected only if multiple grades are included.

Public reporting burden of this collection of information varies from 431 to 2,570 hours with an estimated average of 1,183 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Sample Oral Health Screening Form for Head Start Children

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx

Information obtained by the screener on the day of the screening
Screen Date: / /	Site Code:		Screeners Initials:
Untreated Decay: No Yes	Treated Decay: No Yes		Treatment Urgency: None Early Urgent
Sources to obtain demographic information: From the Head Start program: include the demographic information below on the screening form. From the parent/guardian questionnaire: staple the questionnaire to the screening form. Refer to sample questionnaire on page 53 of the Basic Screening Survey manual.
Sex: Female Male		Date of Birth: / / or Age (Years):      
Hispanic or Latino: No Yes
Race (check all that apply): American Indian/Alaska Native Black/African American Native Hawaiian/Other Pacific Islander Asian White

NOTE:

ASTDD recommends that you use official Head Start data as a primary source for demographics and the parent or guardian consent form or questionnaire secondarily.

Public reporting burden of this collection of information varies from 431 to 2,570 hours with an estimated average of 1,183 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).