Screening Form

[NCCDPHP] Oral Health Basic Screening Survey for Children

2f_screening fields form

Screener Screening Form

OMB: 0920-1346

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Form Approved
OMB No. 0920-1346

Oral health screening fields form


Sample Oral Health Screening Form for School Children




Information obtained by the screener on the day of the screening

Screen Date: / /

School Code:

Screeners Initials:

SSID:

Grade*:

Untreated Decay: No

Yes

Treated Decay: No

Yes

Dental Sealants: No

Yes

Treatment Urgency: None

Early

Urgent




Sources to obtain demographic information:

  • From the school: include the demographic information below on the screening form.

  • From the Department of Education: make sure to include SSID on the screening form. Use the demographic information section below as a guide for collecting the corresponding variables and their categories.

  • From the parent or guardian questionnaire: staple the questionnaire to the screening form. Refer to sample questionnaire on page 56.


Sex: Female

Male

Date of Birth: / / or

Age (Years):      

NSLP: Not Eligible

Eligible

Hispanic or Latino: No

Yes


Race (check all that apply):

American Indian/Alaska Native Black/African American Native Hawaiian/Other Pacific Islander

Asian White

NOTE: ASTDD recommends that you use official data from the Department of Education or schools as a primary source for demographics and the parent or guardian consent form or questionnaire secondarily.

* Grade is collected only if multiple grades are included.


Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1346).



Sample Oral Health Screening Form for Head Start Children

Form Approved
OMB No. 0920-1346




Information obtained by the screener on the day of the screening

Screen Date: / /

Site Code:

Screeners Initials:

Untreated Decay: No

Yes

Treated Decay: No

Yes

Treatment Urgency: None

Early

Urgent


Sources to obtain demographic information:

  • From the Head Start program: include the demographic information below on the screening form.

  • From the parent/guardian questionnaire: staple the questionnaire to the screening form. Refer to sample questionnaire on page 56.


Sex: Female

Male

Date of Birth: / / or Age (Years):      

Hispanic or Latino: No

Yes


Race (check all that apply):

American Indian/Alaska Native Black/African American Native Hawaiian/Other Pacific Islander

Asian White

NOTE:


ASTDD recommends that you use official Head Start data as a primary source for demographics and the parent or guardian consent form or questionnaire secondarily.



Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1346).




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorLin, Mei (CDC/DDNID/NCCDPHP/DOH)
File Modified0000-00-00
File Created2024-09-06

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