Kentucky Dental Screening/examination Form For School Entry - 2010

ADVERTISEMENT

Kentucky Dental Screening/Examination Form for School Entry
August 2010
Kentucky law, KRS 156.160(I), requires proof of a dental screening or examination by a dentist, dental hygienist, physician, registered nurse, advanced
registered nurse practitioner or physician assistant. This evidence shall be presented to the school no later than January 1 of the first year that a five (5) or six
(6) year old is enrolled in public school.
Student Name :_______________________________________________________________
Student Race/Ethnicity: (Please check one)
Last
First
Middle
О 1 White
О 5 American Indian/Alaska
Birthdate: ______/______/______
Gender:
О 0 Male
О 1 Female
О 2 Black/African
О 6 Native Hawaiian/Pacific
American
Islander
Parent or Guardian: ___________________________________________________________
О 3 Hispanic/Latino
О 7 Multi-racial
Name
Relationship
О 4 Asian
О 9 Unknown
Address: ___________________________________ City: ____________________________
Screener’s Name _______________________________
Phone Number: _____________________________
Screener’s Address: _____________________________
_____________________________________________
School: ____________________________________ Date of Enrollment: _____/_____/____
Phone Number: ________________________________
Screening Date: _____/_____/_____
Untreated Decay:
Treated Decay:
(check one)
(check one)
Screener’s Signature: ____________________________
О 0 No untreated cavities
О 0 No treated cavities
Professional Affiliation
(please check one)
О 1 Untreated cavities
О 1 Treated cavities
О Dentist
О Dental Hygienist
О Physician Assistant
О LHD RN
w. KIDS Smiles training
О ARNP
О Physician
Pattern of Early Childhood Cavities:
Treatment Urgency: (check one)
Comments:
(check one)
О 0 No Early Childhood Cavities
О 0 No obvious problem
О 1 Early Childhood Cavities Present
О 1 Early Dental Care Needed
О 2 Urgent care needed
NOTE: Comment required if marked

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Kentucky Dental Screening/examination Form For School Entry - Kentucky Kentucky Dental Screening/examination Form For School Entry - Kentucky Legal
Eye Examination Form For School Entry Eye Examination Form For School Entry Medical
Private Physical Examination Form For School Private Physical Examination Form For School Medical
Form 8453-k - Kentucky Individual Income Tax Declaration For Electronic Filing - 2010 Form 8453-k - Kentucky Individual Income Tax Declaration For Electronic Filing - 2010 Financial
Form 8453-k Draft - Kentucky Individual Income Tax Declaration For Electronic Filing - 2010 Form 8453-k Draft - Kentucky Individual Income Tax Declaration For Electronic Filing - 2010 Financial
Dental Plan Change Form For Employee Dental Plan Change Form For Employee Business
Form Imm. 22 - Application Form For Visa/entry Permit Form Imm. 22 - Application Form For Visa/entry Permit Business
Form Ft 1120fi - Corporation Franchise Tax Report Form For Financial Institutions - 2010 Form Ft 1120fi - Corporation Franchise Tax Report Form For Financial Institutions - 2010 Financial
Form Sb.ee.10.in - Employee Enrollment Form For Small Business - 2010 Form Sb.ee.10.in - Employee Enrollment Form For Small Business - 2010 Medical
Form De 938sef - Quarterly Return Adjustment Form For School Employers - 2014 Form De 938sef - Quarterly Return Adjustment Form For School Employers - 2014 Legal

Related Categories

Parent category: Medical
Download
Go