ࡱ> ikh'` bjbjLULU Ad.?.?|||||||%%%8%4$&2L'L'L'L'L'(((1111111$2h#51|*((**1||L'L'41(-(-(-*p|L'|L'1(-*1(-(-||(-L'@' @ n7%+p(--102(-5+65(-5|(-(h(J(-6)<r)<(((11,d(((2****$||||||  STATE OF NEW JERSEY DEPARTMENT OF CHILDREN AND FAMILIES Division of Prevention and Community Partnerships Contract # _______________ Annex A LEVEL OF SERVICE Section 2.5a School Based Health Centers Unit of Service Definition: One hour of service to, or on behalf of, clients and families expected to be achieved by the end of the contract year. Participant numbers unduplicated unless otherwise noted. School Based Health Site: __________________________________________________________ Date ________________ (Include only one school name. A separate report must be completed for each school funded through the grant) Total # students enrolled in the schoolTotal # registered on Dentrix and Medical Management SystemTotal # of participants receiving Dental servicesTotal # of participants receiving Medical servicesTotal # of participants receiving behavioral health servicesTotal # of participants referred out for services Minimum level of medical service visits: 5370Minimum level of behavioral health service visits325Minimum level of dental visits:3710 Do not leave any boxes blank. If not relevant, place an NA or 0 in the box. ServicesProjected LOS-Use an X to indicate the relevant contract year. ____7/1/12 through 6/30/13 ____10/1/12 through 9/30/13 ____1/1/13 through 12/31/13 IndividualGroupParticipantHoursParticipantHoursDental education and OutreachDental ScreeningFillingsCleaningsHygienistMedicalVisionGYNImmunizationsBehavioral Health Physicals **Note: List the total number of participants attending events for high school(s).     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