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pdfDSR 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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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 Type | application/pdf |
| Author | Jordan, Anthony (HRSA) |
| File Modified | 2023-05-22 |
| File Created | 2023-05-22 |