CORRECTED-DENTAL SEALANT_IGA_PE.PDF

INTERGOVERNMENTAL AGREEMENT
MARICOPA COUNTY
by and through the
DEPARTMENT OF PUBLIC HEALTH
4041 N. Central Avenue, #1400, Phoenix, Arizona 85012

22
1. Agreement No: C-86-20- 2. Agreement Type: Non-Financial Service Agreement
3. Agreement Amount: $0.00 4. Purpose: Dental Sealant

5. Start Date: January 1, 2022 6. Expiration Date: June 30, 2023

This Agreement is entered into by and between Washington Elementary School District (referred to herein as “Schoo! District’),
and Maricopa County, by and through its Department of Public Health (referred to herein after as “County”). School District and
the County are collectively referred to herein as the “Parties” and individually as a “Party.” County, for and in consideration of the
covenants and conditions set forth herein, shall provide and perform the services as set forth below. All rights and obligations of
the Parties shall be governed by the terms of this Agreement, its exhibits, attachments, and appendices, including any
subcontracts or amendments as set forth herein and in:

Section | - General Provisions
Section II - Special Provisions

Section III - Work Statement

This Agreement contains all the terms and conditions agreed to by the Parties. No other understanding, oral or otherwise,
regarding the subject matter of this Agreement shall be deemed to exist or to bind the Parties. Nothing in this Agreement shall
be construed as consent to any lawsuit or waiver of any defense in a lawsuit brought against the County or the School District in
any State or federal Court.

Legal Notice under this Agreement shall be given by personal delivery or by registered or certified mail, postage prepaid, return
receipt requested, to the addresses set forth below and shall be effective upon receipt by the Party to whom addressed unless
otherwise indicated in the notice.

Notice to School District;_Washington Elementary School District Phone: 602-347-2853

Address: 4650 W Sweetwater Glendale, AZ 85304

MCDPH Grants/Contract Unit Phone: (602) 372-0674
4041 North Central Avenue, Suite #1400, Phoenix, Arizona _85012

Notice to County:
Address:

IN WITNESS WHEREOF, the parties enter into this Agreement:

_WASHINGTONALEMENTARY, SCHOOL DISTRICT MARICOPA COUNTY BOARD OF SUPERVISORS

Signature: Signature:
Name: Paul Sta qd Lon Name: Bill Gates
Title: Ougecin tenclent Title: Chairman, Board of Supervisors
Date: [a-10-Abal Date:

ATTEST:

Signature

Clerk of the Board
Date

Pursuant to A.R.S. § 11-952, the undersigned public agency
attorney has determined that this Intergovernmental Agreement
is in proper form and is within the powers and authority granted
under the laws of the State of Arizona.

Signature: a) eRe Ne
Nocera
Date: — L(2o| 2\

Name:

Pursuant to A.R.S. § 11-952, the Attorney for the Board of
Supervisors has determined that this Intergovernmental
Agreement is within the powers and authority granted under the
laws of the State of Arizona.

Signature:

Attorney for Maricopa County
Name:

Date:

SECTION | PROVISIONS

1. EFFECT
To the extent the Special Provisions are in conflict with the General Provisions, the Special
Provisions shall control. To the extent the Work Statement(s) and the Special or General
Provisions are in conflict, the Work Statement(s) shall control.

2. DEFINITIONS

As used throughout this Agreement, the following terms shall have the following meanings:

A. Agreement means this document and all attachments and amendments hereto.
B. School District means the person, firm or organization listed on the Cover Page

of this Agreement.
C. County means Maricopa County, Arizona.
D. Department means the Maricopa County Department of Public Health.

3. GENERAL REQUIREMENTS

A. The terms of this Agreement shall be construed in accordance with Arizona law.
Any lawsuit arising out of this Agreement shall be brought in the appropriate court
in Maricopa County.

B. The County shall, without limitation, obtain and maintain all licenses, permits, and
authority necessary to do business, render services, and perform work under this
Agreement, and shall comply with all laws regarding unemployment insurance,
disability, and workers’ compensation.

C. The County is an independent contractor in the performance of work and the
provision of services under this Agreement and is not to be considered an officer,
employee, or agent of the School District.

4. AMENDMENTS

All Amendments to this Agreement must be in writing and signed by authorized persons
for both Parties. All amendments shall clearly state the effective date of the action.

5. RETENTION OF RECORDS

A. This provision applies to all financial and programmatic records, supporting
documents, statistical records, and other records of the County and School District,
which are reasonably considered as relevant to this Agreement.

B. The County and the School District shall retain all financial books, records, and
other documents related to this Agreement for five (5) years after the expiration
date of this Agreement. County, federal, or State auditors, and any other persons
duly authorized by the County, shall have full access to and the right to examine,
copy and make use of any and all such financial books, records and other
documents.

SECTION | PROVISIONS

10.

11.

ASSIGNMENT AND SUBCONTRACTING

No rights, liability, obligations or duties under this Agreement may be assigned, delegated,
or subcontracted without the prior written approval of the County.

AGREEMENT COMPLIANCE MONITORING

School District shall monitor the County's compliance with, and performance under, the
terms and conditions of this Agreement. On-site visits for compliance monitoring may be
made by the School District and/or its grantor agencies at any time during the School
District's normal business hours, announced or unannounced. During an on-site visit, the
County shall make its records and documents related to work performed or services
provided under this Agreement available to the School District for inspection and copying.

DEFAULT

Either Party may suspend, modify, or terminate this Agreement immediately upon giving
written notice to the other Party that said Party has failed to perform under or otherwise
breached any obligation under this Agreement, or upon the occurrence of any event that
may jeopardize the ability of the noticing Party to perform any of its obligations under this
Agreement.

TERMINATION

A. Either Party may terminate this Agreement at any time by giving the other Party at
least thirty (30) calendar days prior written notice. The notice shall be given by
personal delivery or by registered or certified mail, postage prepaid, return receipt
requested.

B. This Agreement may be terminated by mutual written agreement of the Parties
specifying the termination date therein.

Cc. If not terminated by one of the above methods, this Agreement will terminate upon
the expiration date of this Agreement as stated on the Cover Page of this
Agreement.

TERMINATION FOR BREACH

If either Party defaults under this Agreement and the default continues for more than ten
(10) days after the effective date of the other Party's written notice stating the specific
nature of the default, then the noticing Party may treat the default as a breach of this
Agreement. Upon a breach, the aggrieved Party may exercise any remedy available
under the law, including the termination of this Agreement.

SEVERABILITY
Any provision of this Agreement that is determined to be invalid, void, or illegal by a court

shall in no way affect, impair, or invalidate any other provision hereof, and the remaining
provisions shall remain in full force and effect.

SECTION | PROVISIONS

12.

13.

14.

15.

16.

17.

18.

STRICT COMPLIANCE

Acceptance by the Parties of performance that is not in strict compliance with the terms of
this Agreement shall not be deemed to waive the requirement of strict compliance for all
future performance. All changes in performance obligations under this Agreement must
be in writing and signed by the Parties.

NON-LIABILITY

The School District and its officers, representatives, agents, and employees shall not be
liable for any act or omission by the County or any subcontractor, employee, officer, agent,
or representative of the County or any subcontractor occurring in the performance of this
Agreement, nor shall they be liable for purchases or contracts made by the County or any
subcontractor in connection with this Agreement.

INDEMNIFICATION

Each Party (as "indemnitor") agrees to indemnify, defend, and hold harmless the other
Party (as "indemnitee") from and against any and all claims, losses, liability, costs, or
expenses (including reasonable attorney's fees) (hereinafter collectively referred to as
"claims") arising out of the negligent performance of this Agreement, but only to the extent
that such claims which result in vicarious/derivative liability to the indemnitee are caused
by the act, omission, negligence, misconduct, or other fault of the indemnitor, its officers,
officials, agents, employees, or volunteers.

COVENANT AGAINST CONTINGENT FEES

The County warrants that no person or entity has been employed or retained to solicit or
secure this Agreement upon an agreement or understanding for a commission,
percentage, brokerage, or contingent fee. For breach or violation of this warranty, the
School District may immediately terminate this Agreement without liability.

SAFEGUARDING CLIENT INFORMATION

The use or disclosure by any Party of any information concerning an eligible individual
served under this Agreement is directly limited to the performance of this Agreement.

RIGHTS IN DATA

The Parties shall have the use of data and reports resulting from this Agreement without
cost or other restriction, except as otherwise provided herein or by law. Each Party shall
supply to the other Party, upon request, any available information known to the supplying
Party that is relevant to this Agreement and to the performance hereunder.

NON-DISCRIMINATION

The County, in connection with any service or other activity under this Agreement, shall
not in any way discriminate against any person on the grounds of race, color, religion, sex,
national origin, age, disability, affiliation or belief. The County shall include this clause in
all of its subcontracts related to this Agreement.

SECTION | PROVISIONS

19.

20.

21.

22.

23.

EQUAL EMPLOYMENT OPPORTUNITY

The County shall not discriminate against any employee or applicant for employment
because of race, age, disability, color, religion, sex, or national origin. The County shall
take affirmative action to insure that applicants are employed and that employees are
treated during employment without regard to their race, age, disability, color, religion, sex,
or national origin. Such action shall include, but is not limited to, the following:
employment, upgrading, demotion or transfer, recruitment or recruitment advertising, lay-
off or termination, rates of pay or other forms of compensation, and selection for training,
including apprenticeship. The County shall, to the extent such provisions apply, comply
with Titles VI and VII of the Civil Rights Act of 1964, as amended (42 U.S.C. §§ 2000a, et
seq.); the Rehabilitation Act of 1973, as amended (29 U.S.C. §§ 701, ef seq.); the Age
Discrimination in Employment Act of 1967, as amended (29 U.S.C. §§ 621, et seq.); the
Immigration Reform and Control Act of 1986 (Pub. L. No. 99-603) (“IRCA”); and Arizona
Executive Order 2009-09, which mandates that all persons shall have equal access to
employment opportunities. The County shall also comply with all applicable provisions of
the Americans with Disabilities Act of 1990 (42 U.S.C. §§ 12101, et seq.).

RIGHT OF PARTIAL CANCELLATION

If more than one activity is funded by this Agreement, the Parties reserve the right to
terminate this Agreement or any part thereof without impairing, invalidating or canceling
the remaining Work Statement obligations.

RIGHT TO EXTEND AGREEMENT

Subject to the availability of funds and acceptable County performance, the Parties hereby
acknowledge and agree that they shall have the right to extend this Agreement for
additional one-year periods, not to exceed a total extended term of five (5) years. Any
extension of this Agreement shall be in writing mutually acceptable to and signed by both
Parties.

CIVIL SERVICES DIVISION

The Parties to this agreement acknowledge that they are aware that the Civil Services
Division of the Maricopa County Attorney's Office (Civil Division) may be chosen as the
attorney for other Parties to this agreement, and the signing Party acknowledges that it is
aware of a potential conflict of interest, and it waives any claim of conflict of interest, which
may arise by virtue of Civil Division's representation of other Parties to this agreement.

CERTIFICATION REGARDING DEBARMENT AND SUSPENSION

A. The undersigned, an authorized representative of the County, certifies, to the best
of his or her knowledge and belief, that the County, defined as the primary
participant in accordance with 45 C.F.R. Part 76, and its principals:

1) are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by any federal
department or agency;

2) have not within the 3-year period preceding this Agreement been convicted of
or had a civil judgment entered against them for the commission of fraud or a
5

SECTION |

PROVISIONS

criminal offense in connection with obtaining, attempting to obtain, or performing a
public (federal, State or local) transaction or contract under a public transaction;
violation of federal or State antitrust statues or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or
receiving stolen property;

3) are not presently indicted or otherwise criminally or civilly charged by a
government entity (Federal, State or local) with the commission of any of the
offenses enumerated in paragraph (2) of this certification; and

4) have not within the 3-year period preceding this Agreement had one or more
public transactions (federal, State or local) terminated for cause or default.

If the County is not able to provide this certification, an explanation as to why shall
be attached to this Agreement.

The County shall include, without modification, this Paragraph in all lower tier
covered transactions (i.e., transactions with subcontractors) and in all solicitations
for lower tier covered transactions related to this Agreement.

24, E-VERIFICATION OF EMPLOYEES

The County warrants that it is in compliance with A.R.S. § 41-4401 and further
acknowledges:

A.

That the County and its subcontractors, if any, warrant their compliance with all
federal immigration laws and regulations that relate to their employees and their
compliance with A.R.S. § 23-214;

That a breach of the warranty under subsection A above shall be deemed a
material breach of this Agreement that entitles the School District to, among other
things, immediately terminate this Agreement without liability;

That the School District retains the legal right to inspect the papers of any County
or subcontractor employee who works pursuant to this Agreement to ensure that
the County or subcontractor is complying with the warranty provided under
subsection A above and that the County agrees to make all papers and
employment records of said employee(s) available during normal working hours in
order to facilitate such an inspection;

That nothing herein shall make any County or subcontractor an agent or employee
of the school district.

SECTION Il SPECIAL PROVISIONS

EFFECT

To the extent that the Special Provisions are in conflict with the General Provisions, the
Special Provisions shall control. To the extent that the Work Statement(s) are in conflict
with the Special or General Provisions, the Work Statement(s) shall control.

2. DISPUTES

Except as otherwise provided by law, or otherwise specifically agreed to by the Parties,
any dispute not involving a question of law arising out of this Agreement that is not
resolved between the Parties within a reasonable time, which shall not exceed 120 days,
shall be resolved as follows:

A. Disputes must be filed with the person administering this Agreement for the
County, if one has been appointed, or, if not, with the Department, within ten (10)
days from the date the Parties knew or should have known the basis of the dispute.

B. The person administering this Agreement or the Department, as applicable, shall
respond in writing to the dispute within fourteen (14) days.

C. The Parties may abide by the decision or may choose to resolve the dispute as set
forth in the Mediation/Arbitration Clause of the Special Provisions of this
Agreement.

This Paragraph shall not apply to claims arising from bodily injury, death, or property
damage.

3. MEDIATION/ARBITRATION

In the event that any dispute arises out of this Agreement or involves a recipient of services
under the terms of this Agreement, the Parties shall meet and confer in an effort to resolve
the dispute. In the event that such efforts to resolve the dispute are unsuccessful, the
Parties shall resolve the dispute by arbitration pursuant to A.R.S. § 12-1518(A).

4. CHANGES

A. The Department may, at any time, by written order, make changes within the scope
of this Agreement in any one or more of the following areas:

1). Work Statement activities reflecting changes in the scope of services,
funding source, or County regulations, policies, or requirements.

2). Administrative requirements, such as changes in reporting periods,
frequency of reports, or report formats required by funding source, or
County regulations, policies, or requirements.
3). County schedules and program budgets
B. Any dispute or disagreement caused by such written order shall constitute a
"Dispute" within the meaning of the Disputes Clause of the Special Provisions of
this Agreement and shall be administered accordingly.

7

SECTION II SPECIAL PROVISIONS

5. UNIFORM ADMINISTRATIVE REQUIREMENTS

By entering into this Agreement the County agrees to comply with all applicable provisions
of Title 2, Subtitle A, Chapter Il, PART 200—UNIFORM ADMINISTRATIVE
REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL
AWARDS contained in Title 2 C.F.R. § 200 et seq.

6. LAWS, RULES AND REGULATIONS

The School District and the County understand and agree that this Agreement is subject
to all State and federal laws, rules, and regulations that pertain hereto.

A. Neither this Agreement, nor any portion thereof, may be assigned to another
person by the School District without the written consent of the County's
designated representative. Any attempt by the School District to assign any
portion of this Agreement without the written consent of the County shall constitute
a breach of this Agreement.

B. No assignment shall alter the School District’s responsibility to the County to
assure that all of the provisions under this Agreement are carried out by its
assignee. All terms and conditions in this Agreement shall be included in the
School District's assignments.

7. SPECIAL REQUIREMENTS

A. If the use of subcontractors is approved by School District, the County shall use
written subcontracts or consultant agreements that conform to Federal and State
laws and regulations, and to the requirements of this Agreement appropriate to the
service or activity covered by the subcontract. These provisions apply with equal
force to the subcontract as if the subcontractor were the County referenced herein.
The County is responsible for performing under this Agreement whether or not
subcontracts are used. The County shall submit a copy of each subcontract to the
School District within fifteen (15) days of its effective date.

B. The County shall include in any subcontracts a provision to the effect that the
subcontractor agrees that the School District shall have access to the
subcontractor’s facilities and the right to examine any books, documents, and
records of the subcontract; involving transactions related to the subcontract and
that such books, documents, and records shall not be disposed of except as
provided herein.

8. STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST

Notice is given that pursuant to A.R.S. § 38-511, the County may cancel this Agreement
without penalty or further obligation within three years after execution of this Agreement,
if any person significantly involved in initiating, negotiating, securing, drafting, or creating
this Agreement on behalf of the County is at any time while this Agreement or any
extension of this Agreement is in effect, an employee or agent of any other Party to this
Agreement in any capacity or consultant to any other Party of this Agreement with respect
to the subject matter of this Agreement. Additionally, pursuant to A.R.S. § 38-511, the
County may recoup any fee or commission paid or due to any person significantly involved

SECTION II SPECIAL PROVISIONS

10.

11.

12.

13.

in initiating, negotiating, securing, drafting, or creating this Agreement on behalf of the
County from any other Party to this Agreement arising as the result of this Agreement.

This Agreement may be cancelled pursuant to A.R.S. § 38-511.

POLICY ON CONFIDENTIALITY

The School District and the County understand and agree that this Agreement is subject
to all State and federal laws protecting client confidentiality of medical, behavioral health
and drug treatment information.

SPONSORSHIP ACKNOWLEDGMENT

All promotional materials, brochures, and flyers prepared by the County shall include the
following statement, “Sponsored by MCDPH.”

ISRAEL BOYCOTT

By submitting this Agreement the County certifies that they are in compliance with Article
9, A.R.S. Section 35-393 et seq.

WORKERS’ COMPENSATION

An employee of either party shall be deemed to be an “employee” of both public agencies
while performing pursuant to this Agreement solely for the purposes of A.R.S. § 23-1022
and the Arizona Workers’ Compensation laws. The primary employer shall be solely liable
for any workers’ compensation benefits which may accrue.

Each party shall post a notice pursuant to the provisions of A.R.S. § 23-1022 in
substantially the following form:

“All employees are hereby further notified that they may be required to work under
jurisdiction or control of or within the jurisdictional boundaries of another public agency
pursuant to an intergovernmental agreement or contract, and under such circumstances
they are deemed by the laws of Arizona, to be employees of both public agencies for the
purposes of workers’ compensation.”

FINGERPRINT AND CERTIFICATION REQUIREMENTS/JUVENILE SERVICES

The Fingerprint and Certification Requirements listed in this section apply to this
Agreement to the extent it pertains to services to juveniles.

A. The County shall require that all paid and unpaid personnel who are required or
are allowed to provide services directly to juveniles have met all fingerprint and
certification requirements of A.R.S. §§ 15-512, 36-882 and 36-425.03 and the
School District prior to providing such services.

B. The County shall submit verification of fingerprinting and certification of an
employee by the Department of Economic Security, the Department of Corrections
or the Arizona Supreme Court to meet this requirement.

SPECIAL PROVISIONS

SECTION II
C.
D.
E.
14,

15.

16.

The County shall require and verify that those employees who qualify only for a
restricted certification shall be supervised when providing services directly to
juveniles.

The County shall require that all subcontracts for services to juveniles include a
provision requiring compliance by the subcontractors with A.R.S. §§36-882 and
36-425.03.

This Agreement may be canceled if the fingerprint certifications or the Certification
for Employment required by A.R.S. § 36-425.03 of any employee, including
volunteers (whether or not paid) shows that he or she has committed, been
convicted of, or is awaiting trial for any offense(s) listed on the Certification for
Employment form in this state or similar offenses in another state or jurisdiction.

COMMUNICATION

The County shall assume primary responsibility for effective, efficient communication with
Office of Oral Health Representative.

IT IS MUTUALLY UNDERSTOOD AND AGREED BY AND BETWEEN THE PARTIES

THAT:

A.

This instrument is neither a fiscal nor a funds obligation document. Any endeavor
or transfer of anything of value involving reimbursement or contribution of funds
between the parties to this instrument will be handled in accordance with
applicable laws, regulations, and procedures including those for Government
procurement and printing. Such endeavors will be outlined in separate agreements
that shall be made in writing by representatives of the parties and shall be
independently authorized by appropriate statutory authority. This instrument does
not provide such authority. Specifically, this instrument does not establish
authority for noncompetitive award to the cooperator of any contract or other
agreement

PARTICIPATION IN SIMILAR ACTIVITIES

This agreement in no way restricts Department or School District from participating
in similar activities with other public or private agencies, organizations, and
individuals.

NOTICE:

Any notice given under this Agreement shall be sent to the attention of the following:

Maricopa County Department of Public Health

Dalila

Guerrero

Office of Oral Health

1645 East Roosevelt
Phoenix, Arizona 85006
Phone No.: (602) 506-6946

Email:

dalilaguerrero@mail.maricopa.gov

SECTION II SPECIAL PROVISIONS

Maricopa County Department of Public Health, Grants
and Contracts Unit

Grants and Contracts Administrator

4041 N. Central Avenue, Suite 1400

Phoenix, Arizona 85012

Phone No.: (602) 372-0675

Washington Elementary School District
Attn: Debbie Halverson, RN

1502 W. Mountain View Road

Phoenix, AZ 85021

Phoenix No.: (602) 347-4872

Email: debbie.halverson@wesdschools.org

SECTION Il WORK STATEMENT

Background

Tooth decay is the most prevalent chronic disease currently affecting children, accounting for
approximately 51 million school hours lost each year in the United States. Tooth decay and
resultant pain can have an adverse effect on overall health, good nutrition, self-esteem, and ability
to learn. Among the 43 states that collect data in the same way, Arizona ranks #3 in highest
percentage (over 40%) of third grade children with untreated tooth decay. Conversely, the state
of Washington has the lowest percentage of children with untreated tooth decay (less than 15%)
among the Western states.

Dental sealants are a proven best-practice for reducing tooth decay in the chewing surfaces of
permanent molars. These teeth are best protected if dental sealants are applied soon after these
molars erupt (second and sixth grades). Dental sealants can protect these molar chewing
surfaces from decay for many years. The procedure takes about 15 minutes per child, is pain
free, and requires no “shots” or drilling.

School-based dental sealant programs are evidence-based and provide a safe, inexpensive
model for delivering sealants to school-age children, with less learning time lost. The Maricopa
County Department of Public Health (MCDPH), Office of Oral Health (MCOOH) requests that
Washington Elementary School District join MCOOH in partnership to prevent tooth decay and
improve the health of their second and sixth grade students during the 2017-2018 school year.

This Intergovernmental Agreement (IGA) will bring dental screenings and sealants to eligible
schools in the Phoenix Elementary School District (PESD). A licensed dentist will provide written
take-home findings and a list of dental clinics to a// (insured and uninsured) second and sixth
grade students who return “positive” parental consent forms. The program will then provide dental
sealants to any of these same students who are clinically eligible and uninsured, or currently
enrolled in AHCCCS or KidsCare. These preventive services are provided at no cost to the school
or the child.

1. PURPOSE

The purpose of this IGA is to develop a framework of cooperation between MCDPH and
School District to provide dental sealants to eligible students for the prevention of tooth
decay.

2. STATEMENT OF MUTUAL BENEFIT AND INTERESTS

The mutual benefit for both parties is the prevention of tooth decay for students without
private dental insurance.

3. MCDPH SHALL:

A. Contact and schedule a dental sealant screening date for eligible District Schools
that have submitted a Program application form to MCOOH.

B. Provide program information and parental consent forms, one month in advance
of the scheduled screening date, to the school nurse or designated liaison.

Cc. Provide technical assistance to the school nurse or designated liaison to ensure
successful implementation of the Program.

SECTION Ill

WORK STATEMENT

N.

Provide licensed dentists and dental hygienists, and trained dental assistants to
conduct the dental screening and dental sealant activities at each school.

Check State Board of Dental Examiners licensing records on licensed MCDPH
dental providers; conduct background checks of all dental providers.

Supply identification badges for dental providers.
Instruct all dental providers to register in the school office upon arrival on campus.

Furnish/bring all necessary dental supplies needed to conduct the dental
screening/sealant activities on School District premises.

Ensure that assigned space for conducting the dental sealant activities is returned
to its original condition.

Provide oral health education materials for parents, teachers and school nurse.
Provide community dental clinic information to parents, teachers and school nurse.

Provide program evaluation form for school nurse or liaison to submit following
program completion.

Provide summary reports to each school, which will include information such as
the number of children screened, the number of eligible children needing and
receiving dental sealants, the number of sealants placed and the dollar value, and
a list of students urgently needing dental treatment.

Maintain all student information according to confidentiality requirements.

4. SCHOOL DISTRICT SHALL:

A.

Promote participation in the dental sealant program at district schools through
communication with principals, teachers, school office, and health office
personnel.

Require school health personnel and teachers of second and sixth grade students
to make distribution and receipt of parental consent forms a priority.

Keep returned consent forms separated by class and give them to the dental team
upon arrival.

Provide adequate physical space at each school for the dental screening and
sealant treatment services to be delivered because the school-based dental
sealant program promotes the education function of the District. The space at
each school will include at a minimum:

1) A room or area large enough to accommodate the dental team, equipment,
and several children.
2) A room or area where the equipment may stay overnight if the team needs

to return the following day.

WORK STATEME?

SECTION Ill
3) One table and large trash receptacle per dental team.
4) Accessible electrical outlets.
E Provide assistance (if necessary, or if required) with student identification, release |
and transport from class on the screening and sealant days
Fi Provide outreach to parents/guardians with children having urgent dental needs so

that referrals to dental services occur within 24 hours of the initial dental screening.