0920-23FJ Attachment 2E_Parent consent

Sample Consent Form

Letterhead

Dear Parent or Guardian:

Your child’s school has been chosen to take part in a Colorado Department of Public Health & Environment’s screening survey to assess the dental health status of your child. Dental professionals will screen for the presence of dental caries, sealants, and fluorosis.

The findings of this assessment will be used to assure that our preventive oral health programs are effective. Children need good oral health in order to speak with confidence, express themselves openly, and to be healthy and ready to learn. Studies have shown that children without untreated dental disease miss less school and make higher grades. Data from this assessment will also be used to develop a smart-phone application (i.e., a mHealth tool) that would enable non-dental professionals to determine the prevalence of these three dental conditions by simply taking digital photos of the child’s teeth for Colorado, counties, and individual schools. This information will enable the Colorado Department of Public Health & Environment to more effectively prioritize those schools with the highest need for caries prevention programs.

If you choose to let your child participate, a dental professional will perform a five-minute screening using only a mouth mirror. The dental examiner will also take smart phone images of the front surfaces of your child’s six upper front teeth and intraoral camera images of the chewing surface of all eight permanent molars. They will wear or use new and disposable medical-grade gloves, surgical masks, dental mirrors, and intraoral camera covers for each child. Results of your child’s assessment will be kept private, and your child will not be named in any reports.

Your child will receive a toothbrush and a letter to take home to inform you of the screening results and a list of dentists in your area who accept public insurance. This screening does not take the place of regular dental check- ups. Even if you have a family dentist, we encourage you to participate in this survey. By surveying all children in selected schools, we will have better information to develop the mHealth tool.

Please complete and sign the attached consent form. This will allow your child to be in this survey. Return the form to your child’s teacher by {date}.

As you know, a healthy mouth is part of total health and wellness and makes a child more ready to learn. By letting your child take part in this dental screening, you will help contribute new information that benefits all of Colorado’s children. If you have any questions about this survey, please contact {Susan Smith at (333) 555-5555 x1234 or by email at ssmith@state.doh.gov}.

Sincerely,

Name, Title, Affiliation

Child’s Name:

Yes, I give permission for my child to have his/her teeth checked.

No, I do not give permission for my child to have his/her teeth checked.

Enc.