Run Kindergarten Oral Health Assessment (KOHA) Certificate Tracking and Report — Free

School and Reporting Period Identification

School Name

Full legal name of the school as registered with the state education agency.

School District

Name of the school district.

School Year

Academic year covered by this report (e.g., 2024–2025).

Reporting Period End Date

Date through which certificate data has been collected for this report cycle.

Health Coordinator / School Nurse Name

Name of the staff member responsible for KOHA certificate collection and reporting.

Inspection / Audit Date

Date this compliance inspection is being conducted.

Enrollment and Certificate Submission Status

Total Kindergarten Students Enrolled critical (required)

Count of all kindergarteners enrolled as of the reporting period end date.

Number of Certificates Received (Compliant) critical (required)

Count of students who have submitted a completed, valid Kindergarten Oral Health Assessment certificate signed by a licensed dental provider.

Number of Students with Certificates Pending / Overdue

Count of students whose certificates have not been received by the state-mandated deadline.

Number of Students with Approved Exemptions

Count of students with a documented religious, medical, or other state-approved exemption on file.

Certificate Compliance Rate (%) critical (required)

Calculated as: (Certificates Received ÷ (Total Enrolled − Approved Exemptions)) × 100. Enter the computed percentage.

Certificate Validity and Documentation Quality

All received certificates are signed by a licensed dental provider critical (required)

Confirm that each certificate on file bears the signature and license number of a dentist, dental hygienist, or other state-authorized oral health professional.

Yes No N/A

All certificates include the date of examination critical (required)

Each certificate must show the date the oral health assessment was performed to confirm it falls within the state-required timeframe.

Yes No N/A

All certificates include the student's name and date of birth

Verify that each certificate can be matched to a specific enrolled student by name and date of birth.

Yes No N/A

Assessment findings (caries risk level) are documented on each certificate

Certificates should indicate the oral health finding category (e.g., no apparent problems, early dental disease, urgent referral needed) per KOHA form requirements.

Yes No N/A

Number of certificates rejected due to incomplete or invalid information

Count of certificates returned to families for correction or deemed invalid during this review cycle.

Aggregate Oral Health Findings

Number of students assessed as 'No Apparent Dental Disease'

Count of certificates indicating no apparent caries or urgent dental needs.

Number of students assessed as 'Early Dental Disease / Treatment Recommended'

Count of certificates indicating early-stage caries or other conditions where dental treatment is recommended but not urgent.

Number of students assessed as 'Urgent Dental Care Needed' critical (required)

Count of certificates indicating urgent or emergency dental conditions requiring immediate provider follow-up.

Number of students referred to a dental provider following assessment

Count of students for whom the school issued a dental referral based on certificate findings.

Number of referred students with confirmed follow-up appointment

Of those referred, count of students whose families have confirmed a scheduled dental appointment.

Outreach and Follow-Up for Non-Compliant Students

Written notice sent to families of all students with missing certificates critical (required)

Confirm that a written reminder (letter, email, or app notification) was sent to each family whose student has not yet submitted a certificate.

Yes No N/A

Date of most recent outreach to non-compliant families

Record the date the most recent reminder or follow-up communication was sent.

Dental resource list or community referral information provided to families without a dental home

Confirm that families lacking access to a dentist were provided with a list of local dental clinics, Federally Qualified Health Centers (FQHCs), or state dental access programs.

Yes No N/A

Method(s) used for family outreach

Select all outreach methods used during this reporting period.

Record Keeping, Privacy, and State Reporting Readiness

Certificates stored in a secure, access-controlled location (physical or electronic) critical (required)

Student health records, including KOHA certificates, must be maintained in a confidential manner consistent with FERPA and applicable state student health record laws.

Yes No N/A

State aggregate report submission deadline known and calendared

Confirm that the responsible staff member is aware of the state-mandated deadline for submitting aggregate KOHA data and has it documented.

Yes No N/A

State aggregate report submission status

Current status of the state aggregate oral health report for this reporting period.

Additional notes, corrective actions, or observations

Document any deficiencies identified during this inspection, planned corrective actions, or other relevant observations not captured above.

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Run: Kindergarten Oral Health Assessment (KOHA) Certificate Tracking and Report

School and Reporting Period Identification

Enrollment and Certificate Submission Status

Certificate Validity and Documentation Quality

Aggregate Oral Health Findings

Outreach and Follow-Up for Non-Compliant Students

Record Keeping, Privacy, and State Reporting Readiness

Get your results