Annual Recognition Report Out Healthy Smiles 2020 Practice Name* Practice Address* Practice Identification*PediatricsFamily MedicineFQHCRural Health CenterOtherSection 1 (Bronze)1. Does your practice display the From the First Tooth (FTFT) “Baby Teeth Matter” poster in waiting room/s?Sec 1 Qu 1 Yes No 2. Does your practice provide the From the First Tooth Year by Year trifold and Fluoride Varnish rack card to patients?Sec 1 Qu 2 Yes No 3. Who is your designate FTFT champion?Sec 1 Q 3 A What is his or her email?Sec 1 Q 3 B 4. Did you submit baseline and bi-annual data to the Form the First Tooth website? If not, please upload your data directly after completing this form!Sec 1 Qu 4 Yes No Section 2 (Silver)User needs to successfully complete section 1 to proceed to section 2.5. Has your practice been trained in the past three years to provide fluoride varnish either through an in person training by FTFT or the virtual training on our website?Sec 2 Qu 5 Yes No 6. Are at least half of the practice staff trained who are responsible for the oral health assessments and fluoride varnish?Sec 2 Qu 6 Yes No 7. Does your practice have a system in place to ensure delivery to all children in the practice receiving fluoride varnish (an established workflow)?Sec 2 Qu 7 Yes No 8. Did you submit baseline, bi-annual, and annual data? If not, please upload your data directly after completing this form! Sec 2 Qu 8 Yes No a. Did your data increase toward the annual metric goal?Sec 2 Qu 8a Yes No Section 3 (Gold)User needs to successfully complete section 1 and 2 to proceed to section 3.9. Did your practice reach 50% of children who receive a fluoride varnish in the target age group during the last calendar year?Sec 3 Qu 9 Yes No 10. Does your practice have oral health metrics built into the EHR or documentation system to guide quality improvement and measure performance?Sec 3 Qu 10 Yes No 11. Does your practice document the dental home within the EHR? Sec 3 Qu 11 Yes No 12. Does your practice have a standard clinical workflow in place? Sec 3 Qu 12 Yes No