Form 0920-20PM Data Submission form

BSS Data Submission Form – Elementary School

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

Contact Information

State:      

Primary contact person:       Title:      

Telephone:       Email:      

Survey Methodology

1. School year(s):      

2. Number of schools in sample:      

3. Number of schools that participated:      

4. Did you select replacement schools? No Yes

If YES: How were replacement schools selected:      

5. Percent of children in participating schools eligible for the National School Lunch Program:      

6. Percent of children in sampling frame eligible for the National School Lunch Program:      

7. Are the oral health estimates weighted for the sampling scheme used (check one)?

Yes

No

8. Are the oral health estimates adjusted for non-response (check one)?

Yes

No

9. What type of parental consent did you use (check one)?

Active consent for all schools

Passive consent for all schools

A combination of active and passive consent depending on the school

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).

10. How did you determine the child’s age, sex, race/ethnicity, and NSLP eligibility? (check all that apply)

	Provided by School	Obtained from Department of Education	Parent Questionnaire	Other (please specify)	Not Collected
Age				     
Sex				     
Race/ethnicity				     
NSLP eligibility				     

11. Briefly describe the methods used to collect the oral health indicator data including sampling frame or target population, screening methods, type and number of examiners and examiner training.

     

Please enter data for each grade surveyed into the following section.

Submit the Completed Form to:

Kathy Phipps

Data and Surveillance Coordinator

Association of State & Territorial Dental Directors

Tel: 805-776-3393

Email: [email protected]

Third Grade Specific Information

Number of 3^rd grade children invited to participate:      

Number of 3^rd grade children screened:      

Percent of participating 3^rd grade children eligible for NSLP (if available):      

Indicators	Overall Statewide Estimate			Children in Schools with <50% Eligible for NSLP			Children in Schools with > 50% Eligible for NSLP
	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI
Caries Experience (%)	     	     	     	     	     	     	     	     	     
Untreated Decay (%)	     	     	     	     	     	     	     	     	     
Dental Sealants (%)	     	     	     	     	     	     	     	     	     
Urgent Need for Dental Care (%)	     	     	     	     	     	     	     	     	     

Notes:

CI: confidence interval.

NC: If any data were not collected, enter “NC” in the corresponding estimate field and leave the other fields blank.

NR: If any group has an unweighted denominator (sample size) less than 30, or the relative standard error (RSE) of the estimate is greater than 30%, enter “NR” in the corresponding estimate field and leave the other fields blank. RSE is obtained by dividing the standard error (SE) of the estimate by the estimate; for example, among children with their school-level NSLP percentage ≥ 50%, the prevalence of caries experience is 50% and its SE is 17%, its RSE 34% (=17%/50%) is greater than 30% and thus the estimate for this subpopulation should not be reported and “NR” is entered instead.

Second Grade Specific Information

Number of 2^nd grade children invited to participate:      

Number of 2^nd grade children screened:      

Percent of participating 2^nd grade children eligible for NSLP (if available):      

Indicators	Overall Statewide Estimate			Children in Schools with < 50% Eligible for NSLP			Children in Schools with > 50% Eligible for NSLP
	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI
Caries Experience (%)	     	     	     	     	     	     	     	     	     
Untreated Decay (%)	     	     	     	     	     	     	     	     	     
Dental Sealants (%)	     	     	     	     	     	     	     	     	     
Urgent Need for Dental Care (%)	     	     	     	     	     	     	     	     	     

Notes:

CI: confidence interval.

NC: If any data were not collected, enter “NC” in the corresponding estimate field and leave the other fields blank.

NR: If any group has an unweighted denominator (sample size) less than 30, or the relative standard error (RSE) of the estimate is greater than 30%, enter “NR” in the corresponding estimate field and leave the other fields blank. RSE is obtained by dividing the standard error (SE) of the estimate by the estimate; for example, among children with their school-level NSLP percentage ≥ 50%, the prevalence of caries experience is 50% and its SE is 17%, its RSE 34% (=17%/50%) is greater than 30% and thus the estimate for this subpopulation should not be reported and “NR” is entered instead.

First Grade Specific Information

Number of 1^st grade children invited to participate:      

Number of 1^st grade children screened:      

Percent of participating 1^st grade children eligible for NSLP (if available):      

Indicators	Overall Statewide Estimate			Children in Schools with < 50% Eligible for NSLP			Children in Schools with > 50% Eligible for NSLP
	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI
Caries Experience (%)	     	     	     	     	     	     	     	     	     
Untreated Decay (%)	     	     	     	     	     	     	     	     	     
Dental Sealants (%)	     	     	     	     	     	     	     	     	     
Urgent Need for Dental Care (%)	     	     	     	     	     	     	     	     	     

Notes:

CI: confidence interval.

NC: If any data were not collected, enter “NC” in the corresponding estimate field and leave the other fields blank.

NR: If any group has an unweighted denominator (sample size) less than 30, or the relative standard error (RSE) of the estimate is greater than 30%, enter “NR” in the corresponding estimate field and leave the other fields blank. RSE is obtained by dividing the standard error (SE) of the estimate by the estimate; for example, among children with their school-level NSLP percentage ≥ 50%, the prevalence of caries experience is 50% and its SE is 17%, its RSE 34% (=17%/50%) is greater than 30% and thus the estimate for this subpopulation should not be reported and “NR” is entered instead.

Kindergarten Specific Information

Number of kindergarten children invited to participate:      

Number of kindergarten children screened:      

Percent of participating kindergarten children eligible for NSLP (if available):      

Indicators	Overall Statewide Estimate			Children in Schools with < 50% Eligible for NSLP			Children in Schools with > 50% Eligible for NSLP
	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI	Estimate	Lower 95% CI	Upper 95% CI
Caries Experience (%)	     	     	     	     	     	     	     	     	     
Untreated Decay (%)	     	     	     	     	     	     	     	     	     
Urgent Need for Dental Care (%)	     	     	     	     	     	     	     	     	     

Notes:

CI: confidence interval.

NC: If any data were not collected, enter “NC” in the corresponding estimate field and leave the other fields blank.

NR: If any group has an unweighted denominator (sample size) less than 30, or the relative standard error (RSE) of the estimate is greater than 30%, enter “NR” in the corresponding estimate field and leave the other fields blank. RSE is obtained by dividing the standard error (SE) of the estimate by the estimate; for example, among children with their school-level NSLP percentage ≥ 50%, the prevalence of caries experience is 50% and its SE is 17%, its RSE 34% (=17%/50%) is greater than 30% and thus the estimate for this subpopulation should not be reported and “NR” is entered instead.

Submit the Completed Form to:

Kathy Phipps

Data and Surveillance Coordinator

Association of State & Territorial Dental Directors

Tel: 805-776-3393

Email: [email protected]

B SS Data Submission Form – Head Start

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

Contact Information

State:      

Primary contact person:       Title:      

Telephone:       Email:      

Survey Methodology

12. School year(s):      

13. Number of Head Start sites in sample:      

14. Number of Head Start sites that participated:      

15. Did you select replacement sites? No Yes

If YES: How were replacement sites selected:      

16. Are the oral health estimates weighted for the sampling scheme used (check one)?

Yes

No

17. Are the oral health estimates adjusted for non-response (check one)?

Yes

No

18. What type of parental consent did you use (check one)?

Active consent for all sites

Passive consent for all sites

A combination of active and passive consent depending on the site

Blanket consent previously obtained by Head Start

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).

19. How did you determine the child’s age, sex and race/ethnicity? (check all that apply)

	Provided by Head Start	Parent Questionnaire	Other (please specify)	Not Collected
Age			     
Sex			     
Race/ethnicity			     

20. Briefly describe the methods used to collect the oral health indicator data including sampling frame or target population, screening methods, type and number of examiners and examiner training.

     

Head Start Specific Information

Indicators	Statewide Estimate	Lower 95% CI	Upper 95% CI
Caries Experience (%)	     	     	     
Untreated Decay (%)	     	     	     
Urgent Need for Dental Care (%)	     	     	     

Notes:

CI: confidence interval.

NC: If any data are not collected, enter “NC” in the corresponding statewide estimate field and leave the other fields blank.

Submit the Completed Form to:

Kathy Phipps

Data and Surveillance Coordinator

Association of State & Territorial Dental Directors

Tel: 805-776-3393

Email: [email protected]