Oral Health Assessment/Waiver Request Form Chequeo de Salud Oral
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January 2009 California De partment of Education Return this form to Central Attendance by August 3, 2009 Devuelvan este formulario a la oficina Central de Asistencia antes de Agosto 3, 2009 Original to be retained in child 9s school record. El original quedara en el archivo del estudiante. (1) Oral Health Assessment/Waiver Request Form Chequeo de Salud Oral/ Solicitud de Exoneración California law, Education Code Section 49452.8, now requires that your child have an oral health assessment by May 31 in kindergarten or first grade, whichever is his or her first year of public school.
The law specifies that the assessment must be performed by a licensed dentist or other licensed or registered dental health professional. Oral health assessments that have happened within the 12 months before your child enters school also meet this requirement. If you cannot take your child for this assessment, you may be excused from this requirement by filling out Section 3 on the back of this form.
Section 1 3 Sección 1 To be completed by the parent or guardian Para ser completado por el padre o apoderado Child 9s First Name: Nombre del Estudiant e Last Name: Apellido Middle Initial: Inicial Segundo Nombre Child 9s birth date: Fecha de Nacimiento Address/Direcci ó n: Apt.: City/Ciudad ZIP code/ C ó digo Postal: Sch ool Name/Escuela: Teacher/Maestro(a): Grade/Grado: Child 9s Gender/Sexo: ¡ Male/Masculino ¡ Female/Femenino Child 9s Ethnicity/Etnicidad: Parent/Guardian Name - Nombre del Padre/Apoderado: Section 2 3 Sección 2 Oral Health Data Collection To be completed by the ... more.
dental professional conducting the assessment Para ser completado por el professional dental que realiza el chequeo Assessment Date: Visible fillings present: ¡ Yes ¡ No Visible caries present: ¡ Yes ¡ No Treatment Urgency: ¡ No obvious problem found ¡ Early dental care recommended ¡ Urgent care needed ______________________________________________________________________ Dental professional 9s signature Date ________________________________________ ___________________________________ Return this form to Central Attendance by August 3, 2009 Devuelvan este formulario a la oficina Central de Asistencia antes de Agosto 3, 2009 Original to be retained in child 9s school record. El original quedara en el archivo del estudiante (2) Student Name / Nombre del Estudiante School / Escuela Section 3 3 Sección 3 Waiver of Oral Health Assessment Requirement Exoneración del Requisito de Chequeo de Salud Oral To be completed by a parent or guardian requesting to be excused from this requirement Para ser completado por un padre o apoderado solicitando ser exonerado de este requisito I request that my child be excused from the oral health assessment requirement for the following reason: (Please check the box that best describes the reason.) Solicito que mi hijo(a) sea exonerado(a) del requisito de chequeo de salud oral por la siguiente raz ó n: (Por favor marque el casillero que describe mejor la raz ó n.) I am unable to find a dental office that will take my child 9s insurance plan. No puedo encontrar una oficina dental que acepta mi plan de seguro dental My child is covered by the following insurance plan / Mi hijo esta asegurado por el siguiente plan: Medi-Cal/Denti-Cal Healthy Families Healthy Kids None-Ninguno Other-Otro ______________ I cannot afford an oral health assessment for my child 3 No puedo pagar un chequeo de salud oral para mi hijo(a) I do not wish my child to receive an oral health assessment 3 No deseo que mi hijo(a) reciba un chequeo de salud oral Optional: other reasons my child could not get an oral health assessment: Opcional: otras razones por las cuales mi hijo no pudo obtener un chequeo de salud oral California law requires schools to maintain the privacy of students 9 health information.
Your child 9s identity will not be associated with any report produced as a result of this requir ement. If you have any questions about this requirement, please contact your school office or Carol Zepecki at 650 - 833 - 4263 Signature of parent or guardian Date Firma del padre o apoderado Fecha
