Annual Oral Health Assessment Report
This form is to be completed by the school nurse. Please count the total number of kindergarten and eligible first grade students from your school and fill in the appropriate field. If you have any questions, please contact the Child Health and Disability Prevention (CHDP) Health Promotion Program at (619) 692-8808.
School Name: *
Your answer
School Address:
Your answer
School District: *
Your answer
School Year (20xx - 20xx):
Oral Health Assessment data submitted is usually for the previous school year
Your answer
Name of person completing report:
Your answer
Phone Number:
Your answer
Email Address:
Your answer
Total number of students enrolled in Kindergarten: *
Your answer
Total number of eligible first grade students:
Students enrolled in first grade who were not previously enrolled in public school
Your answer
Total number of students who have completed an oral health assessment: *
This number does not include students who submitted an oral health assessment waiver
Your answer
Total number of students who reported caries experience: *
'Yes' checked under 'Caries Experience' in Oral Health Assessment form
Your answer
Total number of students who reported visible decay present: *
'Yes' checked under 'Visible Decay Present' in Oral Health Assessment form
Your answer
Total number of students who reported early dental care recommended *
'Early dental care recommended' checked under 'Treatment Urgency' in Oral Health Assessment form
Your answer
Total number of students who reported urgent care needed: *
'Urgent care needed' checked under 'Treatment Urgency' in Oral Health Assessment form
Your answer
Total number of students who reported 'Unable to find dental office...' *
'I am unable to find dental office that will take my child's dental insurance plan' in Waiver section of Oral Health Assessment form
Your answer
Total number of students who reported 'Cannot afford...' *
'I cannot afford a dental check-up for my child' checked in Waiver section of Oral Health Assessment form
Your answer
Total number of students who reported 'Do not want...' *
'I do not want my child to receive a dental check-up' checked in Waiver section of Oral Health Assessment form
Your answer
Total number of students who reported 'Other reason...' *
'Other reasons my child did not get a dental check-up' checked in Waiver section of Oral Health Assessment form
Your answer
Total number of students who submitted a Waiver but did not provide a reason *
Your answer
Total number of students who did not submit documentation of Oral Health Assessment or Waiver of Oral Health Assessment *
Students who did not respond/submit any forms
Your answer
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