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2015-2016 Oral Health Assessment

DEADLINE: December 1, 2016

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* 1. District Information

School District Name:

Name of Person Filing Report:

Title:

Email Address:

Phone Number:

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* 2. Total number of students eligible for oral health assessment requirements:

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* 3. Total number of students who presented proof of an assessment:

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* 4. Total number of students with a waiver due to lack of access to a licensed dental professional:

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* 5. Total number of students with a waiver due to no consent:

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* 6. Total number of students with a waiver due to financial burden:

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* 7. Total number of students found to have untreated toot decay:

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* 8. Total number of students who did not respond (no completed form or waiver):

Thank you for submission of the District data.