San Diego Unified School District
2351 Cardinal Lane, Annex B San Diego, CA 92123-3743 (858)627-7580 Fax:(858)627-7444 Nursing & Wellness Program Student Services Office
ORAL HEALTH ASSESSMENT/WAIVER REPORT Due date: June 5th yearly
Date: _____________ Name: _____________________________ School: _____________________ Loc. # _____ Person completing report & Title Days: M T W Th F Phone: _____________________ Ext. ______ Please provide the following information as of May 31st: 1. Kindergarten Enrollment 1. ________
2. First Grade students not previously in a public school 2. ________ 3. Total eligible for assessment (1. + 2.) 4. Assessments (exams) completed for eligible students 5. Waivers signed by parent or guardian: a. unable to find a dental office that will take student’s insurance b. cannot afford a dental check-up c. do not want assessment 6. Total Waivers (a. +b. +c. ) 7. Number who did not return any paperwork to school (either assessment or waiver) 8. Check math: #4. _____+ #6. _____ + #7 _____ = #3 _____
3. _______ 4. _______
a. ______
b. ______ c. ______ 6. _______
7. _______
9. Section 2: Oral Health Data Collection (fill in number of responses) a. Visible decay and/or fillings present Yes ______ No ______ b. Visible Decay Present Yes ______ No ______ c. Treatment Urgency: No Problem _______ Early Dental Care Recommended _______ Urgent Care Needed ______
Due Date: June 5th
Send, fax or email report to Nursing and Wellness Program - Fax: 858-627-7444
HE 913 rev. 7-7-09