Applicant Information

Thank you for your interest in the Protect Tiny Teeth Implementation Project. Please complete the information below and obtain/submit a letter of support per the instructions at the end of page 2 of this form. Applications are due by Friday, December 10. Applicants will be notified of selection by early January 2022.

This application consists of 2 sections: 1) General Application Info 2) Readiness Assessment.  Complete applications include both sections completed (39 questions) and a letter of support sent via email to mcooney@aap.org.  

Question Title

* 1. Please verify that, while interested in oral health, your practice has not fully implemented oral health screening into all well child visits.

Question Title

* 2. Please provide information for the pediatric provider who will take primary responsibility for participating in this project.

Question Title

* 3. Please provide contact information for the staff member who will take primary responsibility for participating in this project.

Question Title

* 4. Organization Name

Question Title

* 5. Number of medical clinics at organization

Question Title

* 6. Number of clinics interested in participating in this project

Question Title

* 7. Number of dental clinics at organization (if any, even if not co-located)

Question Title

* 8. Does the participating site have co-located medical & dental clinics?

Question Title

* 9. Number of clinics with co-located medical & dental services (if any)

Question Title

* 10. Please provide the following information about your practice.

Question Title

* 11. How did you hear about this grant opportunity?

Question Title

* 12. On average, how many well-child visits do you have per month at this participating site? (Note: if you have more than one site interested in participating, please list visit number by site)

Question Title

* 13. Please indicate which languages are spoken by patients and their families/caregivers at your site.

These are the languages that the AAP currently offers the Protect Tiny Teeth patient education materials.  If selected, the AAP can mail you copies of the materials in different languages at your clinic to offer families. 

Question Title

* 14. Please describe your patient mix distribution of insurance coverage

Question Title

* 15. Statement of Interest: Please describe your interest in this quality improvement project and how it would benefit your staff and the patients that you serve.

Question Title

* 16. What are the best days/times for pediatric provider/staff to conference calls?

Question Title

* 17. Which topics are you most interested in hearing about during the 3 webinars? (Please pick 3). 

Question Title

* 18. Are you interested in any of the following incentives for attending the 3 webinars?

Question Title

* 19. To claim CME credit, one needs an AAP ID (which is free to set up online at aap.org), what is your AAP ID #?

T