Form 1 Dental Assessment Form

OMB Control No: 0970-0466

Expiration date: XX/XX/XXXX

Dental Assessment Form

Unaccompanied Children’s Program

Office of Refugee Resettlement (ORR)

General Information

Child

Last name:

First name:

DOB:

A#:

Gender:

Date evaluated:

Time evaluated:

Primary language:

___________________________

Who provided appropriate language services for child during evaluation?

• HCP fluent in child’s primary language

• Trained interpreter

• Not provided

Dental Provider

Name:

Phone number:

Clinic or Practice:

Street address:

City/Town:

State:

Program

Program name:

• Program Staff Member Present During Exam with Dental Provider

Reason for visit:

• Initial Dental Exam (IDE)

• Acute dental care

• Oral prophylaxis

• Follow-up for acute/chronic condition

• Pre-surgical clearance

History and Assessment

Allergies:

• No

• Yes, specify below:

Food

Medication

Environmental

Allergen

Reaction

Dental & Medical History (including dates & locations of care):

Surgeries: _______________________________________________________________________________________________________________________

Hospitalizations: __________________________________________________________________________________________________________________

Chronic/Underlying conditions: ______________________________________________________________________________________________________

Family: _________________________________________________________________________________________________________________________

Currently pregnant:

• No

• Yes

Medications, (dosage frequency & dates):

Past: ______________________________________________________________________________________________________

Current: ___________________________________________________________________________________________________

Concerns Expressed by Child or Caregiver:

• No

• Yes, specify:

Diagnosis and Plan

Diagnosis: Child with complaints, symptoms, diagnoses/conditions; meds prescribed (including OTC); referrals needed:

• No

• Yes, check all that apply:

• Broken tooth/ teeth

• Gingivitis/Gum disease

• Impacted tooth/teeth

• Infection/Abscess

• Missing tooth/teeth

• Tooth decay/Caries

• Tooth sensitivity

• Other, specify: _______________________________________________________

Plan: Check all that apply and specify where indicated. Please provide copies of office notes and lab/imaging results to program staff.

• Child educated on healthcare services received and treatment recommendations

• Medications administered/prescribed:

Medication name	Reason	Date started	Expected end date	Dose	Directions	Psychotropic
						No	Yes
						No	Yes
						No	Yes

• Child has special healthcare needs that require accommodation while admitted in ORR care; specify condition/reason, time frame and frequency:

• Dietary restrictions (e.g., soft foods, liquids): ______________________________________________________________________________________

• Other: _____________________________________________________________________________________________________________________

• Child has/may have an ADA disability: ______________________________________________________________________________________________

• Child is cleared for surgery

• Child has health concerns that require follow-up services; specify needs and time frame by when services should occur:

• Return to clinic: _____________________________________________________________________________________________________________

• Specialist evaluation: ________________________________________________________________________________________________________

• Surgery/Procedure needed/performed: _________________________________________________________________________________________

• Other, specify: ______________________________________________________________________________________________________________

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Child cleared to travel:	Yes, with no restrictions
	Yes, with restrictions (e.g., ground travel, travel safety plan): ___________ __________________________________________________
	No, reason: _____________________________________________________________________________________________________
Recommendations from Healthcare Provider / Additional Information
Dental Provider Signature: ______________________________________________________________ Date: _______ / ______ / __________ Dental Provider Printed Name: ___________________________________________________________

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The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 7 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0466 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact [email protected].