ࡱ>  W bjbj~~  xeexBB7!7!7!T!!!#"?)$ !c5=== >KL)NNL$k<7! O;IKL O O<= >0 QYYY OR=7! >Y OYYF:/ n= j6[OJTg0KPJKnnK7! O OY O O O O O<<cUl O O O O O O OK O O O O O O O O OB M:  SCHOOL HEALTH ANNUAL REIMBURSEMENT REQUEST SYSTEM (SHARRS) This hard copy form is for data consolidation only; submit all information electronically in the annual SHARRS report The SHARRS report is to be electronically submitted by the Superintendent/CEO between May 15 and September 30 or the schools reimbursement will be forfeited When completing this report, refer to the SHARRS Instruction Manual for guidance. The manual is accessible on the Division of School Healths SHARRS webpage at  HYPERLINK "https://www.health.pa.gov/topics/school/Pages/SHARRS.aspx" https://www.health.pa.gov/topics/school/Pages/SHARRS.aspx There is an  SHAPE \* MERGEFORMAT  button on the top right corner on each page of the SHARRS report to aid in completing the report The SHARRS report can be accessed directly at  HYPERLINK "https://apps.health.pa.gov/SHARRS/" https://apps.health.pa.gov/SHARRS/ SCHOOL YEAR: HEALTH DISTRICTCOUNTYVENDOR # / AUNDENTAL PROGRAMDOH USE ONLY ( NW ( SW ( NC ( SC ( NE ( SEDOH USE ONLY FORMCHECKBOX  Mandated Program  FORMCHECKBOX  Dental Hygiene Services ProgramEDUCATIONAL INSTITUTION NAME & ADDRESSINSTITUTION TYPE FORMCHECKBOX  School District  FORMCHECKBOX  Charter School - or -  FORMCHECKBOX  Cyber Charter School  FORMCHECKBOX  Comprehensive Career and Technology Center (CTC)PHONEPHONE EXTN.PENN*LINK E-MAIL ADDRESS At least one of the following contact persons must be a Certified School Nurse. PRIMARY CONTACT PERSON REGARDING REPORT INFORMATION NAME (First and Last):TITLE: FORMCHECKBOX  Business Manager  FORMCHECKBOX  CSN  FORMCHECKBOX  School Dental Hygienist  FORMCHECKBOX  Superintendent/CEO  FORMCHECKBOX  Support Staff  FORMCHECKBOX  OtherPHONE NUMBER (000-000-0000):EXTN.E-MAIL ADDRESS: SECONDARY CONTACT PERSON REGARDING REPORT INFORMATION NAME (First and Last):TITLE: FORMCHECKBOX  Business Manager  FORMCHECKBOX  CSN  FORMCHECKBOX  School Dental Hygienist  FORMCHECKBOX  Superintendent/CEO  FORMCHECKBOX  Support Staff  FORMCHECKBOX  OtherPHONE NUMBER (000-000-0000):EXTN.E-MAIL ADDRESS: ITEMIZED EXPENDITURES (1) INCLUDE expenses for medical/dental reasons; do NOT include expenses related to or leading to academic placement. (2) INCLUDE fee-for-service costs; do NOT include salaries, health, or other fringe benefits. (3) Do NOT INCLUDE expenses related to sports/athletic programs or expenses reimbursed by any other source. 01. SPECIAL MEDICAL, DIAGNOSTIC & TREATMENT SERVICESTOTAL COSTENT (Ear/Nose/Throat) Specialist / Audiologist $Occupational / Physical Therapist $Ophthalmologist / Optometrist$Psychiatrist / Psychologist$OTHER (specify)$TOTAL$(Enter total on ADM/Cost of Services page, section 02, line C. Special Medical, Diagnostic & Treatment Services) 02. MEDICAL SUPPLIES, EQUIPMENT, LAB SERVICES & EDUCATIONAL MATERIALSTOTAL COSTA. Administrative Supplies$B. General Supplies$C. Medical Exam / Health Screening Supplies and Equipment$D. Reference and Educational Materials$TOTAL$(Enter total on ADM/Cost of Services page, section 02, line D, Medical Supplies, Equipment, Lab Services & Educational Materials) 03. SPECIAL DENTAL PREVENTATIVE, DIAGNOSTIC & TREATMENT SERVICES TOTAL COST A. Preventative $ B. Diagnostic $ C. Treatment $ TOTAL $ (Enter total on ADM/Cost of Services page, section 03, line D Special Dental Preventative, Diagnostic & Treatment Services)  04. DENTAL SUPPLIES, EQUIPMENT, FLUORIDE & EDUCATIONAL MATERIALSTOTAL COSTA. Administrative Supplies$B. Dental Exam / Screening Supplies & Equipment / Fluoride Supplies$C. Reference and Educational Materials$TOTAL$(Enter total on ADM/Cost of Services page, section 03, line E, Dental Supplies, Equipment, Fluoride & Educational Materials) AVERAGE DAILY MEMBERSHIP (ADM) AND COST OF SERVICES The ADM is calculated for each grade in the same manner as ADMs reported to the PA Department of Education. ADMs are not enrollment figures; they are calculated by dividing the total aggregate days membership by the number of days school is actually in session. Private/non-public schools should complete the tally form, Determination of Average Daily Membership (ADM), to calculate the ADM per grade and report this data to the School District that provided school health services. Only include K4 students that are an integral part of the school. Do not count if space is only being rented or if the school receives funding for those students from other sources, Ex. Pre K Counts, etc. Report ADMs to the third decimal point; enter 0.000 for grades with no ADMs 01. ADM BY GRADE:02. COST OF MEDICAL SERVICES: GRADE PUBLIC STUDENTS PRIVATE / NON-PUBLIC STUDENTS K4   K   1   2   3   4   5   6   7   8   9   10   11   12   UNGRADED SPEC ED Not applicable per PDENot applicable per PDE OTHER*   TOTAL ADM B.  GRAND TOTAL ADM (Total of Columns A+B above)* The "Other" category is limited to students where a single grade is not assigned in their IEP. An explanation is required in the comment box to describe why a grade level cannot be determined for students listed .: Comments:NOTE: Include students attending part-time Career & Technology Centers (Vo-Techs) in the ADM of each applicable grade. NOTE: Do not include health or other fringe benefits. A. School Physicians $_______ B. Supplemental Staff $________ C. Special Medical, Diagnostic & Treatment Services (Total from Itemized Expenditure page, Section 01) $________ D. Medical Supplies, Equipment, Lab Services & Educational Materials (Total from Itemized Expenditure page, Section 02) $________ TOTAL $________ 03. COST OF DENTAL SERVICES:  NOTE: Do not include health or other fringe benefits. A. School Dentists $________ B. Dental Hygienists $________ C. Dental Assistants $________ D. Special Dental Preventative, Diagnostic & Treatment Services (Total from Itemized Expenditure page, Section 03) $________ E. Dental Supplies, Equipment, Fluoride & Educational Materials (Total from Itemized Expenditure page , Section 04) $________ TOTAL $________ 04. COST OF CERTIFIED SCHOOL NURSING SERVICES: NOTE: Do not include health or other fringe benefits. A. Certified School Nurses (CSN) $________ B. Travel: Costs paid for travel by CSNs directly related to routine and emergency school health services or on behalf of students. Do not include travel to continuing education $________ TOTAL $________ CSN Credentials Professional Personnel ID number (PPID#):  HYPERLINK "https://www.perms.pa.gov/screens/wfpublicaccess.aspx" https://www.perms.pa.gov/screens/wfpublicaccess.aspx Pa RN License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search CSN Assigned School Building(s) Identify School Building Type: Public (P) or Private/Non-Public (NP)Days per Cycle in BldgOROther* Comment requiredStudents in Building (not ADMs)Students per CSN (not ADMs) NAME (as appears on RN license): PA License #:_________________ Expiration Date:___/__/___  FORMCHECKBOX  PDE Certified School Nurse (CSN) *PPID #:________________  FORMCHECKBOX  PDE Emergency Certification *PPID #:________________  FORMCHECKBOX  CPR Certified. CPR Expiration Date: ___/___/____ Name of CPR Course completed: __________________________________ Other Licensed Credential(s):  FORMCHECKBOX  CRNP  FORMCHECKBOX  PA  FORMCHECKBOX  SNP1. FORMCHECKBOX  P  FORMCHECKBOX  NP ___/__2. FORMCHECKBOX  P  FORMCHECKBOX  NP___/__3. FORMCHECKBOX  P  FORMCHECKBOX  NP___/__4. FORMCHECKBOX  P  FORMCHECKBOX  NP___/__Total number of students assigned to the CSN at all buildings (Caseload): ________ *Check Other only when CSNs building assignment varies significantly from week-to-week & cannot be averaged; list # of hours per day/week/month CSN is typically present in the school building. Comment required below describing the Other schedule. The term PRN or As Needed is not an acceptable description. Refer to the INSTRUCTIONS for further detail. Employment Details: __________ Hours/week worked Check all that apply:  FORMCHECKBOX  Job Share  FORMCHECKBOX  Float Pool  FORMCHECKBOX  Administrative duties only (does not carry a caseload).Comment: The term PRN is not an acceptable description  CSN Credentials Professional Personnel ID number (PPID#):  HYPERLINK "https://www.perms.pa.gov/screens/wfpublicaccess.aspx" https://www.perms.pa.gov/screens/wfpublicaccess.aspx Pa RN License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search CSN Assigned School Building(s) Identify School Building Type: Public (P) or Private/Non-Public (NP)Days per Cycle in BldgOROther* Comment requiredStudents in Building (not ADMs)Students per CSN (not ADMs) NAME (as appears on RN license): PA License #:_________________ Expiration Date:___/__/___  FORMCHECKBOX  PDE Certified School Nurse (CSN) *PPID #:________________  FORMCHECKBOX  PDE Emergency *PPID #:________________  FORMCHECKBOX  CPR Certified. CPR Expiration Date: ___/___/____ Name of CPR Course completed: __________________________________ Other Licensed Credential(s):  FORMCHECKBOX  CRNP  FORMCHECKBOX  PA  FORMCHECKBOX  SNP1. FORMCHECKBOX  P  FORMCHECKBOX  NP ___/__2. FORMCHECKBOX  P  FORMCHECKBOX  NP___/__3. FORMCHECKBOX  P  FORMCHECKBOX  NP___/__4. FORMCHECKBOX  P  FORMCHECKBOX  NP___/__Total number of students assigned to the CSN at all buildings (Caseload): ________ *Check Other only when CSNs building assignment varies significantly from week-to-week & cannot be averaged; list # of hours per day/week/month CSN is typically present in the school building. Comment required below describing the Other schedule. The term PRN or As Needed is not an acceptable description. Refer to the INSTRUCTIONS for further detail. Employment Details: __________ Hours/week worked Check all that apply:  FORMCHECKBOX  Job Share  FORMCHECKBOX  Float Pool  FORMCHECKBOX  Administrative duties only (no caseload).Comments: The term PRN or As Needed is not an acceptable description  Supplemental Staff Credentials Pa RN/LPN License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search Do NOT include: 1:1 staff; agency staff, short-term subs, staff hired to assist with screeningsSupplemental Staff Assigned School Building(s)CSN Assigned to Students in BuildingFunction(s)Health CareClericalNAME as appears on license (if applicable):1.  FORMCHECKBOX  FORMCHECKBOX Licensed:  FORMCHECKBOX  RN;  FORMCHECKBOX  LPN Unlicensed:  FORMCHECKBOX  Hours/week worked _____________2.  FORMCHECKBOX  FORMCHECKBOX  PA License #___ _____ Expiration date___/__/___ 3.  FORMCHECKBOX  FORMCHECKBOX 4.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FLOATING: A building assignment that changes from day-to-day/week-to-week rather than having an established schedule. (Comment required below explaining schedule) The term PRN or As Needed is not an acceptable description. 5.  FORMCHECKBOX  FORMCHECKBOX Comments: The term PRN or As Needed is not an acceptable description  Supplemental Staff Credentials Pa RN/LPN License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search Do NOT include: 1:1 staff; agency staff, short-term subs, staff hired to assist with screeningsSupplemental Staff Assigned School Building(s)CSN Assigned to Students in BuildingFunction(s)Health CareClericalNAME as appears on license (if applicable):1.  FORMCHECKBOX  FORMCHECKBOX Licensed:  FORMCHECKBOX  RN;  FORMCHECKBOX  LPN Unlicensed:  FORMCHECKBOX  Hours/week worked _____________2.  FORMCHECKBOX  FORMCHECKBOX  PA License #___ _____ Expiration date___/__/___ 3.  FORMCHECKBOX  FORMCHECKBOX 4.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FLOATING: A building assignment that changes from day-to-day/week-to-week rather than having an established schedule. (Comment required below explaining schedule) The term PRN or As Needed is not an acceptable description. 5.  FORMCHECKBOX  FORMCHECKBOX Comments: The term PRN or As Needed is not an acceptable description  OTHER HEALTH PROFESSIONALS School Physician: Only an MD (Doctor of Medicine) or a DO (Doctor of Osteopathic Medicine) may serve as the School Physician. They may not charge a fee to the students to perform the mandated exams. If a group practice, identify the name of the group and the name/credentials of the Pa licensed physician who assumes medical responsibility for the school. School Dentist: Only a DDS (Doctor of Dental Surgery) or a DMD (Doctor of Dental Medicine) may serve as the School Dentist. They may not charge a fee to the students to perform the mandated exams. If a group practice, identify the name of the group and the name/credentials of the Pa licensed dentist who assumes medical responsibility for the school entity. A School Dentist is still required when a school has an approved Dental Hygiene Services Program (DHSP) Mobile Dentist: A mobile dentist may serve as the School Dentist. They may not charge a fee to the students to perform the mandated exams. If a group practice, identify the name of the group and the name/credentials of the Pa licensed dentist who assumes medical responsibility for the school. A mobile dentist may provide dental services to students in the capacity of a Family Dentist when the mobile dentist does not assume dental responsibility for the school. They may charge a fee to the students to perform the mandated exams. Professional License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search SCHOOL PHYSICIAN NAME as appears on MD/DO licensePennsylvania LicenseLicense Number:________________ Expiration date:__________Group Practice as the SCHOOL Physician?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, Name of Group Practice:_______________ FORMCHECKBOX  No Physician. Comments required (See Chapter 10 of instructions)  SCHOOL DENTISTNAME as appears on DMD/DDS license Pennsylvania LicenseLicense Number:________________ Expiration date:__________Group Practice / MObile Dentist as the SCHOOL Dentist? FORMCHECKBOX  No  FORMCHECKBOX  Yes, Group Practice: Name__________________________  FORMCHECKBOX  Yes, Mobile Dentist Group: Name_____________________MOBILE DENTIST GROUP as a FAMILY Dentist? FORMCHECKBOX  No  FORMCHECKBOX  Yes, Name of Mobile Dentist Group:___________________ FORMCHECKBOX  No Dentist. Comments required (See Chapter 10 of instructions) MANDATED DENTAL SERVICES PROGRAM Dental Examinations by FAMILY Dentist Include dental exams performed by: Family Dentist Mobile Dentist Group NOT in the position of a SCHOOL Dentist (Refer to definitions on the Other Health Professionals page of this report)PUBLIC StudentsPRIVATE/ NON-PUBLIC StudentsTOTAL Students A. Grades K or 1, 3, 7Dental Examinations by SCHOOL Dentist Include dental exams performed by: School Dentist Mobile Dentist in the capacity of SCHOOL Dentist (Refer to definitions on the Other Health Professionals page of this report)PUBLIC StudentsPRIVATE/ NON-PUBLIC StudentsTOTAL Students A. Grades K or 1, 3, 7 B. OTHER Grades C. Referred for Dental Evaluation / Treatment D. Completed Referrals ReportedComplete this section only if the school entity participated in a fluoride program. FLUORIDE PROGRAMPUBLIC StudentsPRIVATE/ NON-PUBLIC StudentsTOTAL Students A. Fluoride MOUTH RINSE Program B. Fluoride TABLET Program C. Fluoride TOPICAL Program DENTAL HYGIENE SERVICES PROGRAM (DHSP) Only schools that received approval from the Department of Health Division of School Health for a Dental Hygiene Services Program (DHSP) should enter information in this section of the report. All DHSP Hygienists must be Certified by the Department of Education All other schools should enter dental information on the Mandated Dental Services Program page; include the School Dental Hygienists employed by the school on the Other Health Professionals page A School Dentist is required when a school has an approved Dental Hygiene Services Program (DHSP) School Dental Hygienist NAME as appears on DH licensePhone/ExtNEmail addressPennsylvania License Professional License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search License Number:________________ Expiration date:__________CERTIFICATION Professional Personnel ID number (PPID#):  HYPERLINK "https://www.perms.pa.gov/screens/wfpublicaccess.aspx" https://www.perms.pa.gov/screens/wfpublicaccess.aspx  FORMCHECKBOX  Not certificated  FORMCHECKBOX  PDE Certified School Dental Hygienist *PPID #:_______________  FORMCHECKBOX  PDE Emergency Certification (requires annual renewal) *PPID #:_______________Additional Pennsylvania Licensure FORMCHECKBOX  PHDHP (Public Health Dental Hygiene Practitioner)  FORMCHECKBOX  Other:__________ License Number:________________ Expiration date:____________DAYS per School Year WorkedDays per School Year Worked____________ School Dental Hygienist NAME as appears on DH licensePhone/ExtNEmail addressPennsylvania License Professional License Number:  HYPERLINK "https://www.pals.pa.gov/#/page/search" https://www.pals.pa.gov/#/page/search License Number:________________ Expiration date:__________CERTIFICATION Professional Personnel ID number (PPID#):  HYPERLINK "https://www.perms.pa.gov/screens/wfpublicaccess.aspx" https://www.perms.pa.gov/screens/wfpublicaccess.aspx FORMCHECKBOX  Not certificated  FORMCHECKBOX  PDE Certified School Dental Hygienist *PPID #:_______________  FORMCHECKBOX  PDE Emergency Certification *PPID #:_______________Additional Pennsylvania Licensure FORMCHECKBOX  PHDHP (Public Health Dental Hygiene Practitioner)  FORMCHECKBOX  Other:__________ License Number:________________ Expiration date:____________DAYS per School Year WorkedDays per School Year Worked____________ DENTAL HYGIENE SERVICES PROGRAM (DHSP) Annual Authorization Plan Request completed for upcoming School Year (SY)___________ Note: Due by April 30. To request DOH approval of your Dental Hygiene Services Program, submit this completed authorization plan between April 1 and April 30 of each year for the upcoming school year. This authorization plan must be submitted electronically through SHARRS on the DHSP Authorization page accessed on the SHARRS Navigation menu. This page has a hard close date of April 30. Due to systems design, schools that submit a written plan or attempt to enter data late are not able to receive approval as a Dental Hygiene Services Program. Any SHARRS user may submit the authorization plan; it does not have to be submitted by the superintendent. Name of School Entity: _______________________________________________ Date: ____________________ School Dental Hygienist *PPID# (Professional Personnel ID number) Act 48 Continuing Professional Education 7 digit number is accessible on the PA Department of Educations (PDE) website. NAME as appears on DH licensePhone/extEmailPennsylvania LicenseLicense Number:_________________________ Expiration date:__________CERTIFICATION as an Educational Specialist Dental Hygienist by the Pennsylvania Department of Education (PDE)  HYPERLINK "https://www.perms.pa.gov/screens/wfpublicaccess.aspx" https://www.perms.pa.gov/screens/wfpublicaccess.aspx FORMCHECKBOX  Not PDE certificated  FORMCHECKBOX  PDE Certified School Dental Hygienist *PPID #:_______________  FORMCHECKBOX  PDE Emergency Certification *PPID #:_______________Additional Pennsylvania Licensure FORMCHECKBOX  PHDHP (Public Health Dental Hygiene Practitioner)  FORMCHECKBOX  Other:_____________________ License Number:__________________________ Expiration date:____________DAYS per School Year Worked_____Days per School Year WorkedComments:  School Dental Hygienist *PPID# (Professional Personnel ID number) Act 48 Continuing Professional Education 7 digit number is accessible on the PA Department of Educations (PDE) website. NAME as appears on DH licensePhone/extEmailPennsylvania LicenseLicense Number:_________________________ Expiration date:__________CERTIFICATION as an Educational Specialist Dental Hygienist by the Pennsylvania Department of Education (PDE)  HYPERLINK "https://www.perms.pa.gov/screens/wfpublicaccess.aspx" https://www.perms.pa.gov/screens/wfpublicaccess.aspx FORMCHECKBOX  Not PDE certificated  FORMCHECKBOX  PDE Certified School Dental Hygienist *PPID #:_______________  FORMCHECKBOX  PDE Emergency Certification *PPID #:_______________Additional Pennsylvania Licensure FORMCHECKBOX  PHDHP (Public Health Dental Hygiene Practitioner)  FORMCHECKBOX  Other:_____________________ License Number:__________________________ Expiration date:____________DAYS per School Year Worked_____Days per School Year WorkedComments:  DENTAL HYGIENE SERVICES PROGRAM (DHSP) (continued) Annual Authorization Plan (SUBMIT IN APRIL FOR APPROVAL FOR THE UPCOMING SCHOOL YEAR) Request for SY_________ Dental Hygiene Services Program (DHSP) Plan: Essential Criteria A School Dentist is required in schools with an approved DHSP1Plan lists the names of the public and private/non-public schools that are part of the DHSP FORMCHECKBOX  Yes FORMCHECKBOX  No2Plan identifies the grades data is collected for "Exams: Family Dentist" (column 01) FORMCHECKBOX  Yes  FORMCHECKBOX  No3Plan identifies the grades identified to receive "Exams/Screens: School Dental Provider" (column 02), and tracks the number of students referred and the number of referrals completed FORMCHECKBOX  Yes FORMCHECKBOX  No4Plan identifies the grades identified to receive "Prophylaxis/Preventive Treatment", optional (column 03) FORMCHECKBOX  Yes  FORMCHECKBOX  No5Plan identifies the grades identified to receive "Dental Health Education/Activities" (column 04) FORMCHECKBOX  Yes  FORMCHECKBOX  No6Plan identifies goals, objectives, methods, and outcome evaluations FORMCHECKBOX  Yes  FORMCHECKBOX  No7Written plan is amended when changes are made to the essential criteria listed in 1 through 6 FORMCHECKBOX  Yes  FORMCHECKBOX  NoDental Hygiene Services Program (DHSP) Plan: Public and Private / Non Public SCHOOLs8List the number of public schools identified to receive dental hygiene services through the DHSP plan. 9List the number of private/non-public schools identified to receive dental hygiene services through the DHSP plan.Dental Hygiene Services Program (DHSP) Plan: Grade identification Place a checkmark in column 01A to identify the grade levels where data will be collected for Exams by the Family Dentist Place a checkmark in columns 02A, 03A, and 04A, respectively, to identify the grade levels where students have been identified to receive dental hygiene services. Add comments in the space provided. During the school year, collect data that will be reported in columns 01B, 02B, 03B, and 04B in the annual SHARRS report.0001020304GRADEExams Family DentistExams / Screens School Dental ProviderProphylaxis / Preventative TreatmentDental Health Education/Activities01 A Check grade(s)01 B Total Students (Count each student once)02 A Check grade(s)02 B Total Students (Count each student once)03 A Check grade(s)03 B Total Students (Count each student once)04 A Check grade(s)04 B Total Students (Count each student once)K4 K123456789101112Ungraded Spec Ed Not Applicable per PDENot Applicable per PDENot Applicable per PDENot Applicable per PDE*OtherTOTAL*NOTE: The Other category is limited to home-schooled and alternative education students when a grade cannot be identified. Students attending part-time CTCs (Vo-Techs) are included in the applicable grades. (DHSP Authorization continued)05Exams / Screens Performed by the School Dental Provider Required in all dental programs  FORMCHECKBOX  Yes 05 AReferred for Further Evaluation/Treatment 05 BCompleted Referrals Reported 06Fluoride Application Program (Optional in DHSP plan):  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, check the appropriate fluoride program:06 AFluoride MOUTH RINSE Program FORMCHECKBOX  Yes  FORMCHECKBOX  N/A06 BFluoride TABLET Program FORMCHECKBOX  Yes  FORMCHECKBOX  N/A06 CFluoride TOPICAL Program FORMCHECKBOX  Yes  FORMCHECKBOX  N/A07 Sealant Application Program (Optional in DHSP plan): FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, identify the provider(s).07 ASealant Application by School Dental Provider (School Dentist, Certified School Dental Hygienist, CSDH /PHDHP) FORMCHECKBOX  Yes  FORMCHECKBOX  N/A07 BSealant Application coordinated through school entity or DHSP plan but services provided by other than the School Dental Provider  FORMCHECKBOX  Yes  FORMCHECKBOX  N/ADental Hygiene Services Program (DHSP) Plan: Approval by School EntityThe written DHSP must be approved by the following professionals when created, amended, and at least every 3 years: Certified School Dental Hygienists (CSDH) or CSDH/Public Health Dental Hygiene Practitioners (PHDHP) School Dentist (The School Dentist has dental responsibility for the school entity) School Administration (Superintendent/CEO, Assistant Superintendent or Pupil Services Director)MM/DD/YYYY1.Month and year when the Certified School Dental Hygienist(s) or CSDH/PHDHP(s) approved the written DHSP plan2.Month and year when the School Dentist approved the written DHSP plan (required even when the CSDH is a PHDHP)3.Month and year when School Administration (Superintendent/CEO, Assistant Superintendent or Pupil Services Director) approved the written DHSP plan Dental Hygiene Services Program (DHSP) Plan: Signature of Authorizing Dentist The Authorizing Dentist assumes supervisory oversight of the Certified School Dental Hygienist(s) (CSDH). Date of signature4.The signature of the Authorizing Dentist must be obtained annually for each CSDH. Note: The signature of an Authorizing Dentist is not required when the CSDH is a PHDHPDental Hygiene Services Program (DHSP) Plan: Certify and SubmitCertification Statement: I hereby certify that this is a true and accurate summary of the Dental Hygiene Services Program plan for the school year of this annual authorization. I certify and accept responsibility for the truthfulness of this information Signature of School Administrator: Name of School Administrator (Print legibly): Comments:  DENTAL HYGIENE SERVICES PROGRAM (continued) Completed AFTER the services were provided in schools with an approved DHSP Dental Hygiene Services Program (DHSP) Plan A School Dentist is required in schools with an approved DHSP1Was the DHSP plan updated/amended since the authorization for this school year was submitted/approved by the Department of Health?  FORMCHECKBOX  Yes  FORMCHECKBOX  No2List the number of public schools that received dental hygiene services through the DHSP plan 3List the number of private/non-public schools that received dental hygiene services through the DHSP planDental Hygiene Services Provided (Public and Private / Non-Public Students Combined) Enter the number of students in each grade who actually received Dental Hygiene Services in Columns 01B, 02B, 03B, and 04B. (Count the student once in each respective column, as applicable)0001020304GRADEExams Family DentistExams / Screens School Dental ProviderProphylaxis / Preventative TreatmentDental Health Education/Activities01 A Check grade(s)01 B Total Students (Count each student once)02 A Check grade(s)02 B Total Students (Count each student once)03 A Check grade(s)03 B Total Students (Count each student once)04 A Check grade(s)04 B Total Students (Count each student once)K4K123456789101112Ungraded Spec EdNot Applicable per PDENot Applicable per PDENot Applicable per PDENot Applicable per PDE*OtherTOTAL*NOTE* The "Other" category is limited to students where a single grade is not assigned in their IEP. 05Follow-up Exams / Screens by School Dental Provider (ALL grades) Enter the number of students who were referred for further dental evaluation/ treatment and number of completed referrals TOTAL Students (Count each student once)05 AReferred for Further Evaluation/Treatment 05 BCompleted Referrals Reported 06Fluoride Application Program: Enter the number of students who actually received fluoride by rinse, tablet, fluoride application in the respective program(s)TOTAL Students (Count each student once)06 AFluoride MOUTH RINSE Program06 BFluoride TABLET Program06 CFluoride TOPICAL Program07Sealant Application Program: Enter the number of students who actually received sealants by the respective dental providerTOTAL Students (Count each student once)07 ASealant Application by School Dental Provider (School Dentist, Certified School Dental Hygienist, CSDH /PHDHP)07 BSealant Application coordinated through school entity or DHSP plan but services provided by other than the School Dental Provider  HEALTH SERVICES STAFF / OTHER ADULTS HEALTH SERVICES FOR STAFF / OTHER ADULTS (Count each instance)Public Staff / Other Adults Private / Non-Public Staff / Other AdultsTOTAL Staff / Other Adults Staff / Other Adult Contacts for Acute / Chronic ILLNESS (count each instance) Staff / Other Adult Contacts for Acute / Chronic INJURY (count each instance)  Staff / Other Adult Emergencies Requiring Activation of Emergency Medical Services (EMS) (count each instance)Staff / Other Adult Emergencies Requiring Use of an Automated External Defibrillator (AED) (count each instance) HEALTH EXAMS, SCREENS & SELECT SERVICES STUDENT HEALTH SERVICES (Count each instance unless specified otherwise)Public StudentsPrivate / Non-Public StudentsTotal Students01Student Contacts for Acute/Chronic ILLNESS (count each instance)02Student Contacts for Acute/Chronic INJURY (count each instance) 03Students REQUIRING SKILLED NURSING procedures ordered by a licensed provider or deemed necessary by CSN (count each student only once)04Students with a plan(s) of care (IHP, ECP, 504 or IEP with a medical component) (count each student only once regardless of the number of care plans in place)05Students Sent from School for Health Reasons (count each instance)06Student Emergencies Requiring Activation of Emergency Medical Services 07Student Emergencies Requiring Use of an Automated External Defibrillator STUDENT PHYSICAL EXAMINATIONS NOTE: Athletic & drivers permit physicals are acceptable as a mandated exam when completed by a medical health care provider other than a chiropractor. (Grades as listed or grades with DOH approved modification)Public StudentsPrivate / Non-Public StudentsTotal Students08Examined by FAMILY Health Care Provider A. Grades K or 1, 6, 11 09Examined by SCHOOL Health Care Provider A. Grades K or 1, 6, 11  B. OTHER Grades C. Referred for Further Evaluation / Treatment D. Completed Referrals ReportedSTUDENT HEALTH SCREENS (Grades as listed or grades with DOH approved modification)Public StudentsPrivate / Non-Public StudentsTotal Students10Vision Screens (K 12) A. Referred for Further Evaluation / Treatment B. Completed Referrals Reported11Hearing Screens (K,1, 2, 3, 7, 11) A. Referred for Further Evaluation / Treatment B. Completed Referrals Reported12Scoliosis Screens (6, 7) Students having 6th grade physicals meet the requirement for the mandated 6th grade scoliosis screen and should be included here A. Referred for Further Evaluation / Treatment B. Completed Referrals Reported13Growth Screens BMI (coincides with the CDC percentile) TOTAL for Grades K 6 A. Underweight Less than 5TH Percentile B. Healthy Weight 5 TH Percentile to Less than 85TH Percentile C. Overweight 85TH Percentile to Less than 95TH Percentile D. Obese Equal to or Greater than 95TH Percentile14Growth Screens BMI (coincides with the CDC percentile) TOTAL for Grades 7 12 A. Underweight Less than 5TH Percentile B. Healthy Weight 5 TH Percentile to Less than 85TH Percentile C. Overweight 85TH Percentile to Less than 95TH Percentile D. Obese Equal to or Greater than 95TH PercentileGRAND TOTAL for Grades K 12  SELECT CHRONIC CONDITIONS STUDENT HEALTH CHRONIC CONDITIONS (Count to be taken annually between March 15 to March 30) Parental reports of a chronic condition are not included on this report- see Chapter 13 Instructions for more guidance on completing this pagePublic StudentsPrivate / Non-Public StudentsTotal Students01Arthritis / Rheumatic Disease02Asthma03Attention Deficit Disorder / Hyperactivity04Bleeding Disorders / Cooleys Anemia05Cardiovascular Condition06Cerebral Palsy07Cystic Fibrosis08Diabetes Type I09Diabetes Type II10Epilepsy / Other Seizure Disorders11Life-Threatening Allergies11 A Food Related Life-Threatening Allergies11 B Other Life-Threatening Allergies ( Example: Bee stings, Latex)12Sickle Cell Disease13Spina Bifida14Tourettes SyndromeTOTAL SERIOUS SCHOOL INJURIES STUDENTS Count each serious school injury to students in public / private schools (combined) When multiple serious injuries occur to a student, count the primary injury category only To be considered a serious school injury, the student must be: Under school jurisdiction (excluding band/other camps, sports injuries that occur during approved PA Interscholastic Athletic Association [PIAA] activities) and Meet at least one of the three following criteria: Emergency Medical Services (EMS) response Immediate care by a physician or dentist, such as, a family health provider, an emergency room physician, a medical or dental specialist The loss of one-half or more days of school The total of EACH subsection (Nature of Injury, Time Period, and Location) must equal one another NATURE OF INJURY01 Burn05 Dental Injury09 Sprain / Strain / Tear (Possible)02 Concussion (Possible)06 Dislocation (Possible)10 Other03 Contusion07 Eye InjuryTOTAL OF SUBSECTION: NATURE OF INJURYCut / Laceration / Puncture08 Fracture (Possible)TIME PERIOD01 After School05 Field Trip09 Sci Lab / Fam & Consumer Sci & Tech Ed Class02 Before School06 Lunch Period10 Other03 Class Change07 P. E. ClassTOTAL OF SUBSECTION: TIME PERIOD04 Class Time08 RecessLOCATION01 Athletic Field / Play Field07 Field Trip13 Sidewalk02 Auditorium / Multipurpose08 Gymnasium / Pool14 Stairs / Ramp / Elevator03 Bus Loading Area09 Playground15 Street / Driveway / Parking04 Cafeteria10 Restroom16 Other05 Classroom11 School Bus / Public BusTOTAL OF SUBSECTION: LOCATION 06 Corridor / Hall12 Sci Lab / Fam & Consumer Sci & Tech Ed Class MEDICATION ADMINISTRATION STUDENTS ONLY  MEDICATION is listed by the Category of Use based on the students condition/diagnosis See Chapter 15 Instructions for guidance on this pageNUMBER OF DOSES ADMINISTERED (Public & Private/Non-public Students Combined)Doses by Individual Order (Primary Care Provider)Doses by Standing Order (School Physician)01Analgesic02AntibioticTOPICAL ANTIBIOTICS ONLY03AnticonvulsantsA. DiastatB. VersedC. Other than Diastat or Versed04Antihistamine / Decongestant A. Epinephrine (include auto-injector)B. Other than Epinephrine05Anti-Inflammatory06Asthma (inhaler, nebulizer, oral, IV)INHALER AND NEBULIZER ONLY07Diabetes A. OralB. Insulin (include bolus/adjustment to insulin pump)C. GlucagonD. Other Glucose Medication (glucose gel / tablet)08GastrointestinalA. Enzymes B. Other than Enzymes09 Reversal Agents: Naloxone/Narcan 10PsychotropicsADD / ADHDOther than ADD / ADHD11Other (exclude: cough drops/lozenges, fluoride supplements, saline, hydrogen peroxide, alcohol, products to treat head lice, oxygen)TOTAL      H511.337 (rev. 7/2019) Page  PAGE 1 of  NUMPAGES 1 H511.337 (rev. 7/2019) SUPPLEMENTAL STAFF ASSISTING CSN Make additional copies as needed Page  PAGE 5 of  NUMPAGES 14 H511.337 (rev. 7/2019) COMMONWEALTH OF PENNSYLVANIA Page  PAGE 4 of  NUMPAGES 14 DEPARTMENT OF HEALTH DIVISION OF SCHOOL HEALTH H511.337 (rev. 7/2019) CERTIFIED SCHOOL NURSES (CSN) Make additional copies as needed Page  PAGE 4 of  NUMPAGES 14 H511.337 (rev.9/ 2012) OTHER HEALTH PROFESSIONALS Page  PAGE 6 of  NUMPAGES 14 H511.337 (rev. 7/2019) Page  PAGE 14 of  NUMPAGES 14  Bureau of Community Health Systems Division of School Health 2?NXYZdeftͼxjXF4F#h(bh'5CJOJQJ^JaJ#h(bh05CJOJQJ^JaJ#h(bhA*5CJOJQJ^JaJh}CJOJQJ^JaJh"BOJQJ^Jh0OJQJ^J hP h<7CJOJQJ^JaJhP CJOJQJ^JaJ hP h8UCJOJQJ^JaJ hP h}CJOJQJ^JaJh2h;YOJQJ^Jh2h}OJQJ^J/jh2hU OJQJU^JhmHnHuPZef{ | *  $:$Ifa$gdcC$:$Ifa$gd]` dh $da$gd} $da$gdb&dgd} dxgdN4 6 z { | ɸsdR@/ hhb&CJOJQJ^JaJ#hh0h (5CJOJQJ^JaJ#hh0hb&5CJOJQJ^JaJhh05CJOJQJ^JaJ#hh0h#V5CJOJQJ^JaJ h- h- CJOJQJ^JaJ h(bh7CJOJQJ^JaJ h(bhakCJOJQJ^JaJ h(bhX8CJOJQJ^JaJ#h(bh- 5CJOJQJ^JaJ#h(bh'5CJOJQJ^JaJ#h(bhl5CJOJQJ^JaJ       ;zhhhYhhD)jhv4hCJOJQJU^JaJh5CJOJQJ^JaJ#h2h<&5CJOJQJ^JaJ#h2hAJ5CJOJQJ^JaJ#h2hb&5CJOJQJ^JaJhh0CJOJQJ^JaJ#hh0hh05CJOJQJ^JaJhh05CJOJQJ^JaJ hh<&CJOJQJ^JaJ hhb&CJOJQJ^JaJ hhh0CJOJQJ^JaJ d e ) * ڹlXI5&h2h}5CJOJQJ\^JaJh!({5CJOJQJ^JaJ&jh!({5CJOJQJU^JaJ4jh!Z5CJOJQJU^JaJhmHnHuh!Z5CJOJQJ^JaJ&jh!Z5CJOJQJU^JaJhMZ<5CJOJQJ^JaJhMZ<CJOJQJ^JaJ$hv4h0JCJOJQJ^JaJ)jhv4hCJOJQJU^JaJ hv4hCJOJQJ^JaJ* . 4 5 @ K T U W X Y e ʹޥ|k|XK>h<75CJOJQJ^Jh}5CJOJQJ^J$hU^Gh}0JCJOJQJ^JaJ hU^Gh}CJOJQJ^JaJ#hU^Gh}5CJOJQJ^JaJ,jhU^Gh}5CJOJQJU^JaJ&hU^Gh}5CJOJQJ\^JaJ h (5CJOJQJ\^JaJ&h2h}5CJOJQJ\^JaJ hh05CJOJQJ\^JaJ hMZ<5CJOJQJ\^JaJ    sdUC1U-h<7"h2hcC5CJOJQJ\^J"h2h<75CJOJQJ\^Jh<75CJOJQJ\^JhLh<7CJOJQJ^Jh>sh<7>*OJQJ^Jh>s>*OJQJ^Jhh>s5>*OJQJ^J"hh5CJOJQJ\^J%hh5>*CJOJQJ\^JhC5>*CJOJQJ\^JhOJQJ^Jh>sOJQJ^Jh<7OJQJ^JhLhN5CJ OJQJ^J  ( +#:$Ifkd$$IfTH4\$ d*~ @   (0*4Haf4p(yt]T ' ( * + / 0 6 7 ; < @ B C F G H K L M Z [ i ɺɺɺɺuiVGhHolhHolCJOJQJ^J%jhHolhHolCJOJQJU^Jh<7B*CJ\ph"h]h<75CJOJQJ\^J h<75\ jh>sh>s5CJh'h<75 jh>sh<75CJh>sh<75CJhLh<7CJOJQJ^J" jhLh<7CJOJQJ^JhLh<7CJOJQJ^J hLh<7hLh<7B*CJ\ph( 4 @ L M Z ~ Mxx$If^M`gd xx$If^gd :$If$:$Ifa$gd]$ J:$Ifa$gd>s J:$Ifi j k l m n u w } ~  ʾ֔~rrc_c_ch<7h<75CJOJQJ\^JhHolCJOJQJ^J+jhHolhHolCJOJQJU^JhHolhHolCJOJQJ^Jhs["CJOJQJ^Jh Lh<7CJOJQJ^Jh LCJOJQJ^Jh<7CJOJQJ^J%jhHolhHolCJOJQJU^J+jhHolhHolCJOJQJU^J 6(($:$Ifa$gd'Pkd$$IfTH4\$ d*~ @    0*4Haf4pytLT  a g_TII x$Ifgds[" x$Ifgdss:$Ifkd$$IfTH40* 0*4Haf4pyts["T        ! 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