PC-OMS-1790 Dental Report of Dental Evaluation

Application Case ID:

A. Chart existing restorations, missing ➤
teeth, and endodontically treated teeth:

❏ Check here if no existing

restorations, missing teeth
or endodontically treated teeth

OR
Comment on findings:

II. Periodontal Evaluation
A. Chart periodontal probings, gingival recession, and mobility
Buccal Pocket Depth
Lingual Pocket Depth
Buccal Recession

Lingual Recession

Lingual Recession

Buccal Recession
Lingual Pocket Depth
Buccal Pocket Depth
Calculus Deposits:

Peace Corps · Report of Dental Examination

❏ Light

❏ Moderate

❏ Heavy

PC-OMS-1790 Dental S (Revised 08/2011)

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Application Case ID:

B. Identify by number all teeth with:
Areas of bleeding upon probing

❏ None

❏ Affected teeth: ___________________________________________________________________________________

Areas of suppuration

❏ None

❏ Affected teeth: ___________________________________________________________________________________

Furcation involvement

❏ None

❏ Affected teeth: ___________________________________________________________________________________

Insufficient attached gingiva

❏ None

❏ Affected teeth: ___________________________________________________________________________________

C. Periodontal Classification:
❏ No Disease

❏ Class I: Gingivitis ❏ Class II: Early Periodontitis
❏ Class III: Moderate Periodontitis ❏ Class IV: Advanced Periodontitis

D. Recommended periodontal therapy:

III. Third Molar Evaluation
❏ Third molars present and asymptomatic

❏ Third molars not present (previously removed or the rare case of having never had them)
❏ Third molars were symptomatic at time of this exam and removal was completed on Date:____________________________________________________

IV. TMJ Evaluation
❏ No history of TMJ

❏ History of TMJ symptoms

Please describe treatment provided, dates, and if symptoms are present at this time:

V. Bruxism
❏ No history of bruxism

❏ History of bruxism

Please describe any bruxism habit, presence of wear facets or need for occlusal guard:

VI. Prosthesis
❏ No prosthesis present

❏ Prosthesis present

Please describe the nature and extent of the prosthesis (e.g., full or partial dentures, bridge, etc.)
and the need for repair or replacement:

Peace Corps · Report of Dental Examination

PC-OMS-1790 Dental S (Revised 08/2011)

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Application Case ID:

VII. Treatment
List all treatment completed after this examination. Do not include treatment planned but not yet completed.
Treatment

Date Completed Signature of Dentist

Ensure the entire form is completely filled out and each box below is checked prior to returning to the Peace Corps. Incomplete exams will be returned.

After examination of this Peace Corps applicant, review of radiographs and treatment rendered as necessary, I attest that the
applicant’s current condition meets the following requirements:
❏ Decayed teeth have been restored or extracted.
❏ Fractured teeth have been restored or extracted.
❏ Fractured restorations have been repaired with a new restoration or the tooth has been extracted.
❏
Advanced periodontal disease that is likely to become symptomatic has been corrected.
❏ Abscessed teeth have been treated with root canal therapy or extraction.
❏ Teeth with irreversible pulpitis have been treated with root canal therapy or extraction
❏ Teeth with previous root canal therapy that is failing have been retreated (either conventionally or surgically) or extracted.
❏ Temporary restorations (including stainless steel crowns) have been replaced with permanent restorations.
❏ Active orthodontic therapy has been completed and the bands removed. Retainers (either fixed or removable) are acceptable.
❏ Third molars, if any, are asymptomatic at time of exam.
❏ TMJ disorder, if present, is asymptomatic at time of exam.

* Important *
Dental examination is complete only when:

 1
2
2
3
4

Dentist’s signature

The dentist has completed all sections of the charting form.
The dentist has attested that by checking each box above, that the applicant has met all the requirements for dental qualification.

Date
Dentist’s license number
State

The dentist has signed and dated the form.
The dentist has listed all treatments completed in Section VII.
The dentist has included one of the following sets of X-rays:
1) A full mouth series, or
2) A Panorex with bitewing X-rays.
· Periapical or Panorex films must be less than 2 years old.
· Bitewing X-rays must be less than 1 year old.
· All films must be original films, not duplicates.
Note: High quality digital X-rays can be accepted. All CDs must be
submitted in a protective cover.

➤ Close-of-service only: The dentist has included bitewing X-rays.

Dentist’s name, address and phone number
For Peace Corps Use ONly
❒ Dental clearance has been completed
❒ Dental X-rays have been submitted as required

Peace Corps · Report of Dental Examination

PC-OMS-1790 Dental S (Revised 08/2011)

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PC-OMS-1790 (Dental)

Peace Corps
Report of
Dental Evaluation

PC-OMS-1790 Dental S
OMB No.: 0420-xxxx
Expiration Date:
Name: (Last, First, Middle Initial)

Peace Corps Use Only

Social Security number

Check one:

Sex M ❒ F ❒

Date of birth (mo / day / yr)

/ /

❏ Pre-service dental exam
❏ In-service dental exam
❏ Post-service dental exam

Home/permanent address
Country of service
Country of service

Telephone No. (

)

HIPAA and Privacy Act Notice:
The information requested is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq., for the purpose of determining
eligibility for Peace Corps service and of documenting the basis for requested payments. Disclosure of this information is voluntary, but failure
to do so will make it impossible for the Peace Corps to determine eligibility and/or pay for these services. This information may be used for
the routine uses described in the Privacy Act, 5 USC 552a, and in the Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50
Fed. Reg. 1950, 1962 (January 14, 1985) regarding the Peace Corps system of records PC-17 (Volunteer records). It may also be subject to
the Health Insurance Portability and Accountability Act (HIPAA) and current effective authorizations.
Confidentiality Notice:
This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged,
confidential, and protected from disclosure by operation of law. If the reader of this message is not the intended recipient, nor the
employee, agent, or other representative responsible for delivering this message to the intended recipient, you are hereby notified that any
dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please
notify me immediately by telephone (202-692-1580) or return email, and permanently delete this message.
Burden Statement:
Public reporting burden for this collection of information is estimated to average 45 minutes per response. This estimate includes the time
for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps,
1111 20th Street, NW, Washington, DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.

I. General Dental Evaluation
Date of exam

(mo / day / yr)

/ /
A. Chart existing restorations, missing ➤
teeth, and endodontically treated teeth:

❏ Check here if no existing

restorations, missing teeth
or endodontically treated teeth

OR
Comment on findings:

Peace Corps · Report of Dental Examination

PC-OMS-1790 Dental S (Revised 08/2011)

Page 1 of 4