SEAlS Administration -- Add Event - Child/Programs

2b Data Collection Form Paper.docx

[NCCDPHP] Sealant Efficiency Assessment for Locals and States (SEALS)

SEAlS Administration -- Add Event - Child/Programs

OMB: 0920-1289

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ATTACHMENT 2b. Form Approved

OMB N0. XXXX-XXX

Section 7. Sealant Event Data Collection Form


Event Date(s) ­­­­­­­­­­­­­­__________________________ School ___________________________

Consent Forms Distributed _______________

Labor


Dentist

Hygienist

Assistant

Other

Total hours at school1





Total hours travelling to and from school2





Total miles travelling to and from school2






Vehicles

Number owned/operated by SSP driven to event


Total miles driven for event



Services delivered (Only complete if your program will not input child-level data into SEALS.)

Number of children screened


Number of children receiving sealants


Number of teeth sealed


Number of children receiving fluoride varnish


Number of children receiving prophy3





Detailed Child-Level Data Collection Form (complete one form per child)


Program Name: _____________________ Event (School/dates): ____________________________________

Patient ID4 #: _________________ Age: _________ (4 to 18 years) Date: ______________ Grade: ______

Insurance: _________________________

Race

Ethnicity

Latino


Asian


Non-Latino


Black or African American


Unknown


White




American Indian or Alaska Native




Native Hawaiian or Other Pacific Islander




Unknown


Check one box for both race and ethnicity:












  1. Screening


Chart for program use: D = decayed, F = filled, M = missing due to disease, S = sealant present,
PS = prescribe sealant, RS = recommend reseal, no mark = no treatment recommended


1

2

3

4

5

12

13

14

15

16

Sealant Prescriber’s Signature/Date

___________________________________

Fluoride Prescriber’s Signature/Date


___________________________________























32

31

30

29

28

21

20

19

18

17


Comments:

Data for SEALS


Sealants Present:

No/Yes


Untreated Decay:

No/Yes

Treated Decay:

No/Yes

Referral:

None

Not urgent

Urgent

Number of decayed/filled 1st molars:

(0–4) =_________________


  1. Preventive Services


Chart for program use (Mark with an “S” the teeth where sealants were placed.)


1

2

3

4

5

12

13

14

15

16

Provider’s signature


________________________






















Date


________________________

32

31

30

29

28

21

20

19

18

17

Comments:




Number of 1st molars

sealed:

(0–4) =_________________

Number of 2nd molars

sealed:

(0–4) =_________________

Number of other permanent teeth sealed:

(0–8) =_________________


Number of primary teeth sealed:

(0–8) =_________________


Fluoride varnish provided:

No/Yes

Prophylaxes provided:

No/Yes

Data for SEALS



  1. Follow-Up


Chart for program use (Mark with an “R” teeth where sealants were retained.)


1

2

3

4

5

12

13

14

15

16

Evaluator’s Signature


_________________________























Date


_________________________

32

31

30

29

28

21

20

19

18

17

Comments:




Data for SEALS


Number of teeth with a retained sealant (0–8)





1 If SSP uses reusable instruments, hours spent on sterilizing instruments offsite should be included in school hours.

2 Only complete if your SSP reimburses workers for this item.

3 Delivered with low-speed hand piece or power scaling.

4 Each child’s ID# must be unique for that event; do not use duplicate ID#’s at any one event. Programs must ensure complete confidentiality of each child.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorBrailer, Cassie (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2023-11-01

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