ࡱ> OQN_ 6bjbj 8@jA\jA\   zz8,B\F#n(. """""""$$j'"Q%|"zz_#3"3"3"Xz8"3""3"3"3"`ѷbuqL3"u"#0F#3"))3")A"4s^3"L""!|F#) > @: California Department of Education March 2008 Page  PAGE 1 of  NUMPAGES 1 Oral Health Assessment Form California law (Education Code Section 49452.8) states your child must have a dental check-up by May 31 of his/her first year in public school. A California licensed dental professional operating within his scope of practice must perform the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3. Section 1: Childs Information (Filled out by parent or guardian) Childs First Name: Last Name:Middle Initial:Childs birth date:Address: Apt.: City: ZIP code:School Name: Teacher:Grade:Childs Sex: % Male % FemaleParent/Guardian Name:Child s race/ethnicity: % White % Black/African American % Hispanic/Latino % Asian % Native American % Multi-racial % Other___________ % Native Hawaiian/Pacific Islander % Unknown Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional) IMPORTANT NOTE: Consider each box separately. Mark each box. Assessment Date:Caries Experience (Visible decay and/or fillings present) % Yes % NoVisible Decay Present: % Yes % NoTreatment Urgency: % No obvious problem found % Early dental care recommended (caries without pain or infection; or child would benefit from sealants or further evaluation) % Urgent care needed (pain, infection, swelling or soft tissue lesions)  Licensed Dental Professional Signature CA License Number Date Section 3: Waiver of Oral Health Assessment Requirement To be filled out by parent or guardian asking to be excused from this requirement Please excuse my child from the dental check-up because: (Check the box that best describes the reason) #-34:;<=ABLMNOPklm}X Y > ııĪyjyYLh05>*OJQJ^J h0h0CJOJQJ^JaJh06CJOJQJ^JaJh0CJOJQJ^JaJh0CJ OJQJ^JaJ h0OJQJ^Jh05OJQJ^J h(h(%h(CJOJQJ^JaJmHnHu#jh(CJOJQJU^JaJh(CJOJQJ^JaJhCJOJQJ^JaJhEgCJOJQJ^JaJ#.PlmX Y $If$a$gd( B<<<<$Ifkd$$IfTl\ !'  Q t0O)644 la>p(yt0T  tnnn$Ifkd$$IfTl0!'Q t0O)644 la>pyt0T     $ 1 6 tnnnnnn$Ifkdz$$IfTl0!'Q t0O)644 la>pyt0T6 8 d F D>>11 $Ifgd0$Ifkd$$IfTl\ !'  Q t0O)644 la>p(yt0T <>D&(Xnllll`` $$Ifa$gd0kd$$IfTl0 !'  t0O)644 la>pyt0T$If $&0&(DF 8:kkY=7jh0h0>*CJOJQJU^JaJmHnHu#h0h0>*CJOJQJ^JaJ(h0h0CJOJQJ^JaJmH sH h0h0CJOJQJ^JaJh0h0OJQJ^J#h0h0>*CJOJQJ^JaJ h0h0CJ OJQJ^JaJ h0h0CJOJQJ^JaJh0CJOJQJ^JaJh05CJOJQJ^JaJ h05>*CJOJQJ^JaJXt$If $7$8$H$Ifgd0 $$Ifa$gd0 `D>>>>>>$Ifkd$$IfTl\S 1&*Hl t0*644 la p(yt0T^`bd|~NPR. / ///V0ɵxi[M?=[/[/[h0CJ OJQJ^JaJ Uh0CJOJQJ^JaJh0CJOJQJ^JaJh0CJOJQJ^JaJh0>*CJ OJQJ^JaJ h05OJQJ^Jh05CJOJQJ^JaJ h0h0CJOJQJ^JaJ#h0h0>*CJOJQJ^JaJ&h0h056CJOJQJ^JaJ7jh0h0>*CJOJQJU^JaJmHnHu4jh0h0CJOJQJU^JaJmHnHu`bd|~NPR. / ///V0^$a$rkdf$$IfTl&** t0*644 la p yt0T% I am unable to find a dental office that will take my child s dental insurance plan. My child s dental insurance plan is: % Medi-Cal/Denti-Cal % Healthy Families % Healthy Kids % Other ___________________ % None % I cannot afford a dental check-up for my child. % I do not want my child to receive a dental check-up. Optional: other reasons my child could not get a dental check-up: If asking to be excused from this requirement: (____________________________________________________ Signature of parent or guardian Date  Return this form to the school no later than May 31 of your child s first school year. Original to be kept in child s school record.     Return this form to the school by May 31, 20___ Original to be retained in child s school record. Page 2 of 2 The law states schools must keep student health information private. Your child's name will not be part of any report as a result of this law. This information may only be used for purposes related to your child's health. If you have questions, please call your school. 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VB  C D"?VB   C D"?VB  C D"?B S  ?& E >tE (t t&0*$t OLE_LINK7 OLE_LINK8 F  F hhhhhhhhhmmF ww  F 9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsState    1 2 C F  2 C F 3333PMUVMMEEPPvv88!1127ACDKY\^_`g||      , 3 ? ? o w # / 1 2 A B B F P 1 2 C F  @(b0EEg @L1111E @ .UnknownG*Ax Times New Roman5Symbol3. *Cx Arial?Wingdings 35. .[`)TahomaA$BCambria Math"1hxR&bEE2f   !v4 ?qHP  ?(2!xx UOral Health Assessment Form - Health Services & School Nursing (CA Dept of Education)YOral Health Assessment/Waiver Request Form to accompany the parental notification letter.Kelly HaarmeyerOh+'00dp|      (XOral Health Assessment Form - Health Services & School Nursing (CA Dept of Education)\Oral Health Assessment/Waiver Request Form to accompany the parental notification letter. Normal.dotmKelly Haarmeyer10Microsoft Office Word@H'@lh@Pς@Nu ՜.+,D՜.+,t px  VJennifer RoussevCA Dept of Education  VOral Health Assessment Form - Health Services & School Nursing (CA Dept of Education) Title P ,4Xx_NewReviewCycle_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleID_ReviewingToolsShownOnce` need JUST English versionRobyn.Keller@cda.orgKeller, Robynq  "#$%&'(*+,-./0123456789:;<=?@ABCDEGHIJKLMPRoot Entry F5buRData !1Table))WordDocument8@SummaryInformation(>DocumentSummaryInformation8FCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q