SBOHP Learning Opportunity Application Form

School-Based Oral Health Learning Opportunity | Application Form

Please complete the application below to be considered for participating in the school-based oral health program (SBOHP) learning opportunity. Up to two clinics will be selected to participate in the project. Catalyst staff will inform all applicants of their status in late January. Refer to the SBOHP project description webpage for more information and project details.

For questions, contact Ericca Facetti.

SBOHP Learning Opportunity Application 2022

Clinic Information
Clinic Name*
Clinic Address*
Street Address Address Line 2 City State ZIP Code
Please list all cities and/ or counties that you serve*
What type of clinic?*
- Federally Qualified Health Center
- Free/Charitable Clinic
- Hybrid Model
- Other
If you chose "Other" above, please briefly describe your answer.
Is your clinic located in a dental health professional shortage area (DHPSA)?*
Use this link to determine if your clinic is located in a DHPSAs in Virginia: https://data.hrsa.gov/tools/shortage-area/hpsa-find
- Yes
- No
Does your facility have a school-based oral health program?*
- Yes
- No
If yes, please list which schools you currently serve.
Please list any schools or counties you would like to be partnered with for this project.
Use this to connect with new or different schools in your service area. If you don't have a preference, you can leave this space blank.
Describe the need for a school-based dental program in your service area specifically.*
Explain how the purpose of this project aligns with your facility's goals.*
Outline your facility's existing capacity and infrastructure to provide services in schools.*
This includes clinical staff, administrative support, previous experience, equipment, etc.
List the types of oral health services you would like to provide in schools.*
Dental sealants must be included.
Explain your proposed data collection process, which would ensure continuous monitoring of SBOHP performance.*
Dental sealants must be included.
Participant Information
Please include contact information for the individuals from your clinic who will participate in this project and represent the clinic at meetings. It is important to build a multidisciplinary team for projects such as this to balance the duties, gain different perspectives and input, and strengthen the sustainability of your work. Possible team members could include dental staff, administrative/front desk staff, clinic executive, or data/IT staff. At least two people must be included on the application, but more are encouraged!
Participant #1: Name*
First Last
Email*
Job title*
Phone*
Participant #2: Name*
First Last
Email*
Job title*
Phone*
Participant #3: Name
First Last
Email
Job title
Phone

Virginia Health Catalyst’s mission is to ensure all Virginians have equitable access to comprehensive healthcare that includes oral health. The Virginia Department of Health (VDH) Dental Health Program was awarded federal funding from the Health Resources and Service Administration (HRSA) to advance strategies that enhance the oral health workforce in Virginia.

This program is generously supported by the Virginia Department of Health through VDH HRSA Workforce Grant HRSA-18-014. VDH funding may not cover direct care or legislative activities.

School-Based Oral Health Learning Opportunity | Application Form

SBOHP Learning Opportunity Application 2022

Clinic Information

Participant Information

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