SEAlS Administration -- Add Event - Child/Programs

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) =_________________

2. 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

3. 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.