If you have questions or need the help of an interpreter, please call your school office.
Si tiene alguna pregunta o si necesita la ayuda de un interprete, favor de llamar a la oficina de su escuela. Yog koj muaj lus nug los yog xav tau neeg pab txhais lus, thov hu rau koj lub tsev kawm ntawv.

NS D-6		Rev. 01/10 CLOVIS UNIFIED SCHOOL DISTRICT

Dear Parent/Guardian:

Effective January 1, 2007, California Education Code Section 49452.8, required all children entering public school for the first time to have a dental check-up. The Education Code specified that the dental check-up must be done by a licensed California dental healthcare professional.

If your child has had a dental check-up within 12 months PRIOR to entering school, that check-up will meet this requirement. Please have your child’s dentist complete Section 2 of the “Oral Health Assessment Verification Form” on the backside of this letter.

Clovis Unified is committed to promoting the health and wellness of its students. If you child has not had a dental check-up within the 12 months PRIOR to entering school, the school your child will be attending will schedule an onsite dental screening with a local volunteer dentist provided through the Fresno-Madera Dental Society sometime between February and March. You will be notified in advance of the screening date.

If you do not want your child to participate in this assessment, please complete Section 3 of “Oral Health Assessment Verification Form” on the backside of this letter and return it to the school your child will be attending in the fall.

If you do not have dental coverage for your child, you may be income-eligible for coverage through one of the State of California’s low-cost insurance plans. To find out more information regarding the insurance plans, please contact Amy Gomez at 327-7988.

Sincerely,

Jeanne Prandini, RN, MSN, CPNP Coordinator
CUSD Nursing Services

JP/gad

ADDITIONAL INFORMATION PRINTED ON THE BACKSIDE

ORAL HEALTH ASSESSMENT VERFICATION FORM

Effective January 1, 2007, California law (Education Code Section 49452.8) required a dental check-up for all children entering a public school for the first time.

This assessment must be performed by a licensed California dental professional operating within their scope of practice. If your child has had an oral health examination within the last 12 months prior to entering school for the first time, that exam will meet the State’s requirement. Please completed Section 1, have your child’s dentist complete and sign Section 2 and return the form to your child’s school nurse.

If your child has not had an oral assessment done within the last 12 months, your child’s school nurse schedules an annual dental check-up at school which is performed by a local volunteer dentist during the months of February and March.

If you do not want your child to have the oral assessment done at school or by your child’s dentist, please complete Section 3 of this form.

SECTION 1: Child’s Information (to be completed by the parent/guardian)

Child’s name: 	               Birthdate: 	           Gender: M / F (circle one)

Address: 	
City	Zip Code

School Name: 	      Teacher Name/Grade: 	

Parent/Guardian Name: 	

Child’s race/ethnicity (√ one)	⁪ ⁪ ⁪

White
American Indian Asian

⁪ Black/African American ⁪ Alaska Native
⁪ Multi-racial

⁪ Hispanic/Latino
⁪ Native Hawaiian/Pacific Islander ⁪ Unknown

SECTION 2: Oral Health Data Collection (to be completed by a licensed California dental professional)

IMPORTANT NOTE: Consider each box separately. Mark each box.

Assessment Date:
	
Caries Experience (visible decay and and/or fillings present)
⁪ Yes	⁪ No
	
Visible Decay Present:

⁪ Yes	⁪ No
	Treatment 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)

CA License Number 	       Date 	
Licensed Dental Professional Signature

SECTION 3: Waiver of Oral Health Assessment Requirement (to be completed by the parent/guardian)

Please excuse my child from the dental check-up because: Please check √ box that best describes the reason.

⁪ I am unable to find a dental office that will take my child’s dental insurance plan. My child’s dental insurance 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: 	

Signature of Parent/Guardian 	                 Date 	

The law states school 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 relating to your child’s health. If you have any questions, contact your child’s school nurse.