Forms

 

Preventive Services Program (PSP): Back to School Message  from Dr. Guy Deyton, DDS, State Dental Director

COVID-19 Protocol for Preventive Services Program (PSP) – 2021

School Nurses – Key to Good Oral health during COVID-19 Infographic 8.20

Considerations for School Nurses in Return to School: Dental Screening

Please Read This Document First – PSP Planning Guide (updated 10/2021)

1. Parental Consent Form for Screening and Fluoride Varnish – English – Spanish
   OR Parental Consent Form for Varnish Only – English  –  Spanish  (COVID-19 statement added)
2. PSP Order Form
3. PSP Event Tracking Form (Please print for use at event.)
4. Oral Health Screening Results Form – English and Spanish
5. Fluoride Varnish Home Care Instructions – English – English and Spanish
6. Cover Sheet and Mailing Instructions
7. Submit Mandatory PSP Event Report Online
8. PSP Screening Form 

New Online PSP Screening Form (New as of July 2020)

PSP Online Screening Form (link)

PSP Online Screening Form Instructions

• Process is simple, quick and no paper screening forms used.
• The link to the Online PSP Screening Form is above.  Click on the link to access the form and simply complete the form for each student/child.  Instructions on using the Online PSP Screening Form is above.
• Confirm with the screeners they are comfortable using their personal device to collect PSP Oral Screening Data.
• The day of the PSP Event share the Online Screening Form Instructions above with your screener(s).
• If on the day of the PSP event you are not able to use the Online Screening Form, please make paper copies of the PSP Screening Form located above (#8), and order a return envelope or mailing box.

Additional Resources

* Material Safety Data Sheet for Nu Shield Fluoride Varnish
* PSP Event Set-up Floor Plan Sample Set-up
* Volunteer Recruiting Letter – Dental Professionals

Returning PSP screening forms

1. If you have 1 – 150 screening forms, use the postage paid return envelope (manila) included in your order to return the completed forms.
2. If you have 151 + screening forms, use the return mailing box included in your order to return the completed screening forms.  Attach the enclosed adhesive postage paid label to the box.
3. Your mail carrier with the United States Postal Service will pick up the envelope/box with your regular outgoing mail.
4. You will still be required to complete a cover sheet for each batch of screening forms mailed.
5. Do not return any blank screening forms or unopened fluoride varnish.

Receiving Ordered Supplies

• The order placed using the online PSP Order Form will arrive within 3-5 business days via UPS.
• Please check the order thoroughly once it arrives to determine if any items are missing or buried among the other supplies.
• If your order has not arrived within the expected 3-5 days, please check with your office staff to ensure that the order was not misplaced within the building before contacting your Oral Health Consultant to investigate the whereabouts of your order.

Thank you for participating in the Preventive Services Program!