Form 0920-20PM School Participation Form

Invitation to schools to participate

Sample Letter to Principals – #1, Positive Consent

Letterhead

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

Dear Principal,

Your school has been selected to participate in a state-wide assessment of the oral health of elementary school students during the 2019-2020 school year. The assessment {Oral Health Basic Screening Survey} is funded by the {state} State Department of Health {and the US Centers for Disease Control and Prevention} {in cooperation with the Office of State Superintendent of Public Instruction}.

The findings of this assessment will be used to assure that our preventive oral health programs are effective. Children need good oral health in order to speak with confidence, express themselves openly, and to be healthy and ready to learn.

Schools throughout the state have been randomly selected for participation in the assessment. Selected third grade {and grade} children with a signed consent from a parent or caregiver, will be given a free dental screening. The screening will take about one minute per child. No x-rays will be taken and no dental treatment will be provided.

We understand that minimal class disruption is essential in the operation of your school. For this reason, each school will only be asked to participate for {one} day. Each participating child will receive a toothbrush and a letter to the parent or caregiver noting the results of the screening. Your school will incur no cost for participating.

We would like to ask for your support and the support of your staff to carry out this important assessment of our children’s oral health needs. Attached are sample consent and results forms. Parents/caretakers may also provide verbal consent in order to reduce their burden and mediate the chance a student will lose the form.

The state coordinator is Jane Doe, RDH. She will be contacting you to answer your questions and to receive your support for conducting the assessment. Her telephone number is (555) 555-5555 and her email is [email protected].

As you know, poor oral health has been related to decreased school performance, poor social relationships, and less success later in life. For this reason, we thank you in advance for making this contribution to the health and well-being of our children in {state}.

Sincerely,

{state} Health Department {state} Department of Education

Name, title

Contact info

Enclosure

CC: state or local DOE

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 Letter to Principals – #2, Positive Consent and Questionnaire

Letterhead

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

Dear Principal,

Your school has been selected to participate in a statewide assessment of the oral health of elementary school students during the 2019-2020 school year. The assessment is funded by the {state} State Department of Health {and the US Centers for Disease Control and Prevention} {in cooperation with the Office of State Superintendent of Public Instruction}.

The findings of this assessment will be used to assure that our preventive oral health programs are effective. Children need good oral health in order to speak with confidence, express themselves openly, and to be healthy and ready to learn.

Schools throughout the state have been randomly selected for participation in the assessment. Selected third grade {and grade} children with a signed consent from a parent or caregiver, will be given a free dental screening. The screening will take about one minute per child. No x-rays will be taken, and no dental treatment will be provided.

We understand that minimal class disruption is essential in the operation of your school. For this reason, each school will only be asked to participate for {one} day. Each participating child will receive a toothbrush and a letter to the parent or caregiver noting the results of the screening. Your school will incur no cost for participating.

We would like to ask for your support and the support of your staff to carry out this important assessment of our children’s oral health needs. Attached are sample consent and results forms. Parents/caretakers may give verbal consent in order to reduce their burden and mediate the chance a student will lose the form. The state of {State} is also assessing the challenges of families to access oral health care, therefore on back of the consent form is an optional questionnaire for families to complete and return.

The state coordinator is Jane Doe, RDH. She will be contacting you to answer your questions. Her telephone number is (555) 555-5555 and her email is [email protected].

As you know, poor oral health has been related to decreased school performance, poor social relationships, and less success later in life. For this reason, we thank you in advance for making this contribution to the health and well-being of our children in {state}.

Sincerely,

{state} Health Division {state} Department of Education

Name, title

Contact info

Enclosure

CC: state or local DOE

Public reporting burden of this collection of information varies from 433 to 2603 hours with an estimated average of 1,206 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 Letter to Principals – #3, Passive Consent and Option for Questionnaire

Letterhead

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

Dear Principal,

Your school has been selected to participate a state-wide assessment of the oral health of elementary school students funded by the {state} State Department of Health {and the US Centers for Disease Control and Prevention} {in cooperation with the Office of State Superintendent of Public Instruction}.

The findings of the Oral Health Basic Screening Survey will be used to assure that our preventive oral health programs are effective. Children need good oral health in order to speak with confidence, express themselves openly, and to be healthy and ready to learn.

Schools throughout the state have been randomly selected for participation in the assessment. Selected third grade {and grade} children will be given a free dental screening. The screening will take about one minute per child. No x-rays will be taken and no dental treatment will be provided.

We understand that minimal class disruption is essential in the operation of your school. For this reason, each school will only be asked to participate for {one} day. Each participating child will receive a toothbrush and a letter to the parent or caregiver noting the results of the screening. Your school will incur no cost for participating.

We would like to ask for your support and the support of your staff to carry out this important assessment of our children’s oral health needs. Attached are sample consent and results forms. {The state of {State} is also assessing the challenges of families to access oral health care, therefore an optional questionnaire for families to complete and return is included.}

The state coordinator is Jane Doe, RDH. She will be contacting you to answer your questions. Her telephone number is (555) 555-5555 and her email is [email protected].

As you know, poor oral health has been related to decreased school performance, poor social relationships, and less success later in life. For this reason, we thank you in advance for making this contribution to the health and well-being of {state}’s children.

Sincerely,

{state} Health Department {state} Department of Education

Name, title

Contact info

Enclosure

CC: state or local DOE

Public reporting burden of this collection of information varies from 433 to 2603 hours with an estimated average of 1,206 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).