Form 1 Dental Exam Form

OMB Control No: 0970-0466

Expiration date: XX-XX-XXXX

Dental Exam Form Unaccompanied Children’s Program Office of Refugee Resettlement (ORR)

General Information

Minor

Last name:

First name:

DOB: ____/____/______

A#:

Gender:

Dental Provider

Name:

Phone number:

Clinic or Practice:

Street address:

City or Town:

State:

Date of visit: ____/____/______

Program

Program name:

Program Staff Member Present During Exam with Dental Provider

Dental History

Concerns Expressed by Minor or Caregiver:

Diagnosis and Plan

Diagnosis: Minor with complaints, symptoms, diagnoses/conditions; meds prescribed (including OTC) or referrals needed:

No

Yes, check all diagnoses that apply. Specify in the space provided, where indicated.

Broken tooth or teeth

Gingivitis/Gum disease

Impacted tooth/teeth

Infection/Abscess

Tooth decay/Caries, specify how may: _____________

Tooth sensitivity

Other, specify:

Plan: Check all that apply and specify in the space provided.

Return to clinic:

PRN/As needed

Follow-up (specify condition, timing): ______________________________________________

Minor fit to travel:

No

Yes: _________________________________________________________________________________

Per program staff, discharge from ORR custody will be delayed:

No

Yes: ___________________________________________

Minor has/may have an ADA disability:

No

Yes: ________________________________________________________________

Referred to specialist: _________________________________________________________________________________________

Medications given (specify name, reason, date started, dose, and directions and indicate if psychotropic): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Dietary restrictions:___________________________________________________________________________________________

Surgery/procedure needed/performed: ___________________________________________________________________________

Other: ______________________________________________________________________________________________________ Recommendations from Healthcare Provider / Additional Information Dental Provider Signature: __________________________________________________ Date: _______ / ______ / __________ Dental Provider Printed Name: __________________________________________________________

2 of 3

The purpose of this information collection is to provide ORR with critical health information for unaccompanied children in the care of ORR. Public reporting burden for this collection of information is estimated to average 5 minutes per healthcare provider, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. §279: Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK [C.D. Cal. 1996]). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0466 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact UACPolicy@acf.hhs.gov.