Screening Form

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).