Appendix A SCHOOL FLUORIDE MOUTHRINSE PROGRAM ORDER/REPORT FORM DATE: 1. School Information: Name of School: Name of School District: Mailing Address: City County State Zip: Name of Primary Contact: Phone #: ( ) Email: Fax: ( ) Secondary Contact: Phone #: ( ) Email: Fax: ( ) 2. Shipping Information: Do you want your shipment sent to the address above? [ ] Yes [ ] No (if NO provide address below) Name of School: Street Address: City: State: Zip: Attn: Phone #: ( ) 3. Program Participation for the 2015-2016 school year Are children enrolled from areas without fluoride in their drinking water? [ ] Yes [ ] No Check all grades participating [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 [ ] 8 4. Program Participation for the 2015-2016 school year Total # of children expected to receive 5 ml (10mg mouth rinse) (Grade 1) Total # of children expected to receive 10 ml (20mg mouth rinse (Grade 2-8) Total # of cases of fluoride rinse in storage? (10 mg) (20 mg) And their corresponding expiration dates? (10 mg) (20 mg) 5. Completion of Form Person preparing this form: Title: Email: Signature: Date: Please return this form to the New York State Oral Health Center of Excellence by either 1) Scanning and email to school@nysoralhealth.org, 2) fax to 585-325-2293 with attention to OHCE, or 3) Mail to 259 Monroe Avenue, Level B, Rochester, NY 14607
Appendix B: Fluoride Mouthrinse Program Parent Permission Form Dear Parent/Guardian: New York State Department of Health and the New York State Department of Education is offering to elementary school students a fluoride mouthrinse program to prevent dental decay. This simple method of applying fluoride is safe and effective in controlling tooth decay, and requires only a few minutes of classroom time. Participants will rinse their mouths in school under direct supervision with a 0.2% neutral sodium fluoride solution for one minute once a week. The ingredients in the clear pre-mixed, individual fluoride mouth rinse unit dose are sodium fluoride, potassium sorbate, saccharin sodium, citric acid, and purified water. These ingredients are also common to toothpaste and other over-the-counter dental care products. This is a rinse and spit procedure and therefore not intended for swallowing. Studies show that a weekly fluoride mouthrinse reduces tooth decay. We encourage you to allow your child to participate in this valuable preventive program. Your child's participation is entirely voluntary and you may withdraw your child from the program at any time. For the current school year the program will be completely funded by the New York State Department of Health, Bureau of Dental Health and your child may participate at NO COST. This Fluoride Mouthrinse Program is, however, in no way a substitute for routine dental care. Your child must continue proper home care habits and routine dental checkups. The Guidelines for Administration of Medication in Schools April 2002 by New York State Education Department states, "Designated staff in the school setting, following assignment and in conjunction with approval by school nurse personnel, may assist self-directed students with the taking of their own oral, topical, and inhalant medication." Please read and return the completed form by to your child's teacher. Sincerely, Superintendent Signature: ==================================================================== PARENTAL PERMISSION FORM Fluoride Mouthrinse Program I give permission for my child to participate in the Fluoride Mouthrinse Program. I understand that my child s name, date of birth and teacher will be listed on the prescription for fluoride mouth rinse and released to the NYSDOH, Bureau of Dental Health. I agree my child is self-directed and can rinse with fluoride in the classroom under direct supervision. I do not want my child participating in the Fluoride Mouthrinse Program. Our drinking water at home is fluoridated YES NO Parent/Guardian Signature: Address: Phone#: Child s Name: Grade: Room # School Name: PLEASE COMPLETE AND RETURN BY THANK YOU
Appendix C Fluoride Mouthrinse Prescription Form (Grade: 1) School: School District: School Address School Year 2015-2016 Phone: ( ) Rx for the School Based Administration of Fluoride Mouthrinse Student s Name Date of Birth Teacher 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Sodium Fluoride 0.2% solution: Sig. 5 ml, once a week, to be swished around teeth in the mouth for approximately 1 minute and then expectorate out. Name: Address: Signature: Date: / / Dentist, Physician, Nurse Practitioner Please send completed forms to: NYS Oral Health Center of Excellence Address: 259 Monroe Avenue, Level B, Rochester, NY 14607 Phone: 585-325-2280, x7315 FAX: 585-325-2293 Email: school@nysoralhealth.org
School: Appendix D Fluoride Mouthrinse Prescription Form (Grades: 2, 3, 4, 5, 6, 7, 8) School District: School Address School Year 2015-2016 Phone: ( ) Rx for the School Based Administration of Fluoride Mouthrinse Student s Name Date of Birth Teacher 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Sodium Fluoride 0.2% solution: Sig. 10 ml, once a week, to be swished around teeth in the mouth for approximately 1 minute and then expectorate out. Name: Address: Signature: Date: / / Dentist, Physician, Nurse Practitioner Please send completed forms to: NYS Oral Health Center of Excellence Address: 259 Monroe Avenue, Level B, Rochester, NY 14607 Phone: 585-325-2280, x7315 FAX: 585-325-2293 Email: school@nysoralhealth.org
Appendix E Fluoride Mouthrinse Program: Changes in School Nurse Information If there should be a change in the school nurse for your school, please fill out this form and return to the NYS Oral Health Center of Excellent - Fluoridation Program Coordinator at the New York State Department of Health. The form can be faxed or mailed to: New York State Oral Health Center of Excellence Address: 259 Monroe Avenue, Level B, Rochester, NY 14607 Phone: 585-325-2280, x7315 Fax: 585-325-2293 Email: school@nysoralhealth.org School Name School Address School Phone Number Name of new FMP Coordinator Changes, comments, or concerns:
Appendix F Fluoride Mouthrinse Program- Teacher Checklist Preliminary Steps 1. Send any permission slips received to the School Nurse. 2. Review Fluoride Mouthrinse Program Classroom Roster (Appendix H) to identify participating students. 3. Schedule a weekly time for rinsing, preferably the same day and time each week. 4. Consider providing a mini dental lesson while the students are rinsing. 5. Obtain the amount of single dose cups that you need for the weekly rinsing session. Rinsing Steps 1. Review instructions with children as needed. 2. Assist any students that need help removing the foil lid. 3. Instruct students to rinse for one minute. 4. Do not swallow. 5. Have students empty the solution from their mouth into the cup. 6. Ask students to wipe their mouth with the napkin provided. 7. Have students place the napkin in the cup to absorb used fluoride. 8. Ask students to dispose of the cup in a proper trash receptacle. 9. Allow 30 minutes before eating and drinking. 10. Return any unused rinse to the locked storage area Contact your school nurse if you have questions.
Appendix G Fluoride Mouthrinse Program Classroom Participation School Name Year Grade Teacher Class Enrollment # Students Rinsing
Appendix H Fluoride Mouthrinse Program - Classroom Roster Teacher Grade School Year Children Participating in Program (signed consent received) 1. 19. 2. 20. 3. 21. 4. 22. 5. 23. 6. 24. 7. 25. 8 26. 9. 27. 10. 28. 11. 29. 12. 30. 13. 31. 14. 32. 15. 33. 16. 34. 17. 35. 18. 36. Circle the day of the week the class rinses: M T W TH F Enter the date each week the date your class rinsed: September October November December January February March April May June Retain until the end of the year and return to the school nurse for the annual report.
Appendix I FLUORIDE MOUTHRINSE - SAFETY ASSESSMENT 1. Name of School 2. Name of Principal 3. Name of the School Nurse 4. Nurse Contact Information Address City State Zip Code Telephone Number Email Address 5. Where are the fluoride mouthrinse supplies stored? Indicate specific location in the school. (Reminder: All fluoride mouthrinse must be kept in a locked, climate controlled storage area away from children.) 6. Are all school personnel knowledgeable of the Fluoride Mouthrinse Misuse Protocol? Yes No 7. Has everyone directly involved with administering the fluoride mouthrinse received training and signed the Training Certification? Yes No SIGNATURE - Principal Date Signed SIGNATURE School Nurse Date Signed Please return this form to: New York State Oral Health Center of Excellence 259 Monroe Avenue, Level B, Rochester, NY 14607 Phone: 585-325-2280, x7351 Fax: 585-325-2293 Email: school@nysoralhealth.org
Appendix J Fluoride Mouthrinse - Safety Procedures Accidental ingestion of fluoride by children usually does not present a serious risk if the amount of fluoride ingested is less than 5mg/Kg of body weight. If there were a problem with toxicity, it usually would be apparent within an hour. The symptoms are an upset stomach, nausea, vomiting, diarrhea, and abdominal cramps. Due to rapid onset of symptoms, please call New York Poison Center as soon as possible. If a student is suspected of swallowing at one time, MORE than the recommended daily dose: 1. Try to determine the type of fluoride, the amount of fluoride ingested, the child s approximate weight and the length of time since ingestion. 2. Call the New York Poison Center (1-800-222-1222) and follow the instructions. 3. If the New York Poison Center is not available by phone, proceed as follows: a. Administer one glass of milk. b. Do not induce vomiting. c. If milk or dairy products are unavailable or if the child is lactose intolerant, administer antacids or a glass of water d. Contact parents and take the child to indicated source of health care e. If parents cannot be reached, take child to local emergency provider. 4. In every case, notify your School Nurse. School Nurse contact information (fill in name of the School Nurse designated for your school here): Please contact New York State Oral Health Center of Excellence for further assistance. Phone: 585-325-2280, x7315 Fax: 585-325-2293 Email: school@nysoralhealth.org
Appendix K Fluoride Mouthrinse - Misuse Protocol Accidental ingestion of fluoride mouthrinse by children usually does not present a serious risk if the amount of fluoride ingested is less than 5mg/Kg of body weight. If there were a problem with toxicity, it usually would be apparent within an hour. The symptoms are an upset stomach, nausea, vomiting, diarrhea, and abdominal cramps. Due to rapid onset of symptoms, please call New York Poison Control Center as soon as possible (1-800-222-1222). If child swallows dispersed amount of mouthrinse in a single-dose cup: 1. Do not panic this amount will not hurt the child. 2. In rare cases the child may feel slightly nauseous. The child may have a serving of milk or ice cream to relieve the nausea. 3. Document the date and amount swallowed. 4. Notify the school nurse. 5. Have the child practice with water prior to administering the next scheduled dose. Depending on the situation, this may need to be done for a couple of weeks prior to resuming the fluoride mouthrinse. The student needs to be able to demonstrate the ability to swish without swallowing prior to resuming the fluoride mouthrinse program. If a student is suspected of swallowing at one time, MORE than the recommended daily dose: 1. Immediately notify your School Nurse. 2. Try to determine the type of fluoride, the amount of fluoride ingested the child s approximate weight, and the length of time since ingestion. 3. Call New York Poison Center (1-800-222-1222) and follow their instructions. 4. If the New York Poison Center is not available by phone, proceed as follows: a. Administer one glass of milk. b. Do not induce vomiting. c. If milk or dairy products are unavailable or if the child is lactose intolerant, administer antacids or a glass of water. d. Contact parents and take the child to indicated source of health care. e. If parents cannot be reached, take child to local emergency provider. School Nurse contact information (fill in name and contact information of the School Nurse designated for your school here): (Display this protocol in the area where children use the fluoride mouthrinse)
Appendix L Fluoride Mouthrinse Program - Training Certification I,, certify that I have received the training needed to participate in the weekly fluoride mouthrinse program at (name of school). I understand the material covered including: proper technique for storing the fluoride mouthrinse materials and the guidelines for distributing and supervising the rinse. Signature Date School Nurse Signature Date School Nurse Keep in your records and update at the beginning of each school year.