Oral Health Assessment - California Department Of Education
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1
2California Department of Education
Oral Health Assessment
California law, Education Code Section 49452.8, now requires that your child have an oral
health assessment by May 30 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 of this form.
Section 1
To be completed by the parent or guardian
Child’s First Name:
Last Name:
Middle Initial:
Child’s birth date:
Address:
Apt.:
City:
ZIP code:
School Name:
Teacher:
Grade:
Child’s Gender:
□ Male
□ Female
Parent/Guardian Name:
Child’s race/ethnicity:
□ White
□ Black/African American
□ Hispanic/Latino
□ Asian
□ American Indian
□ Alaska Native
□ Native Hawaiian/Pacific Islander
□ Multi-racial
□ Unknown
Section 2
Oral Health Data Collection
To be completed by the dental professional conducting the assessment
Assessment
Visible caries
Visible caries present:
Treatment Urgency:
□ Yes
□ No obvious problem found
Date:
and/or fillings
□ No
□ Early dental care
present:
□ Yes
recommended
□ No
□ Urgent care needed
______________________________________________________________________
Dental professional’s signature
Date
Return this form to the school by May 30
Original to be retained in child’s school record.
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