1 DSR Proposed Changes

Ryan White HIV/AIDS Program Part F Dental Services Report

Tab B - Dental Services Report Proposed Changes

OMB: 0915-0151

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DSR OMB Package 2023 – Proposed Changes
SECTION 2. PATIENT DEMOGRAPHICS AND ORAL HEALTH SERVICES
#
8

Variable
HIV/AIDS Status

9a

Gender

9b

Sex at birth

10

Pregnancy Status

11a

Ethnicity

11b

Hispanic subgroup

12a

Race

12b

Asian subgroup

Response Option
• HIV-positive, not AIDS
• HIV-positive, AIDS status unknown
• CDC-defined AIDS
• HIV-indeterminate (infants <2 years old)
• Male
• Female
• Transgender Male to Female
• Transgender Female to Male
• Transgender Other
• Unknown
• Male
• Female
• Pregnant
• Not pregnant
• Unknown/unreported
• Hispanic, Latino/a
• Non-Hispanic/Latino/a
• Mexican, Mexican American, Chicano/a
• Puerto Rican
• Cuban
• Another Hispanic, Latino/a or Spanish
origin
•
•
•
•
•
•

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
More than one race

•
•
•
•
•
•
•

Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian

Recommendation
No change

No change

No change
No change

No change
No change

No change

No change

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February 16, 2023, V1

DSR OMB Package 2023 – Proposed Changes

12c

Native
Hawaiian/Pacific
Islander subgroup

13

Age

14

Income

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
<13
13-24
25-34
35-44
45-54
55-64
≥65
Unknown/unreported
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

No change

No change

No change

Section 5: Additional Dental Reimbursement Program Information
#
23a

Variable
Amount of
unreimbursed costs

Response Option
Total unreimbursed costs of oral health care
provided to patients with HIV during the
reporting period (rounded to the nearest
dollar)

Recommendation
No change

Section 6: Additional Community-Based Dental Partnership Program Information
#
28

Variable
Indicate which of the
following populations were
specially targeted to
receive services through
the Community-Based
Partnership Program
(check all that apply)

Response Option
• Urban populations
• Suburban
populations
• Rural populations
other than migrant
or seasonal
workers
• Migrant or
seasonal workers
• Runaway street
youth
• Gay, lesbian,
bisexual,
transgender youth

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February 16, 2023, V1

Recommendation
• Urban populations
• Suburban
populations
• Rural populations
other than migrant
or seasonal
workers
• Migrant or
seasonal workers
• Runaway street
youth
• Gay, lesbian,
bisexual,
transgender youth

DSR OMB Package 2023 – Proposed Changes
Gay, lesbian,
bisexual,
transgender adults
• Homeless persons
• Incarcerated
persons
• Substance-addicted
persons
Other, specify
•

•
•
•

•
•
•

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February 16, 2023, V1

Gay, lesbian,
bisexual,
transgender adults
Homeless persons
Incarcerated
persons
Paroled persons
Substance-addicted
persons
Other, specify


File Typeapplication/pdf
AuthorJordan, Anthony (HRSA)
File Modified2023-05-22
File Created2023-05-22

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