Community Dentistry Initiative 2010 Survey

1. Please provide an estimate of the value of the dentistry you provide each year at your office to individuals who would not be likely to otherwise receive treatment. This figure represents care you provided knowing the individual(s) were unable to pay.

	Please indicate for 2009
$100 to $1,000 per year	*Please provide an estimate of the value of the dentistry you provide each year at your office to individuals who would not be likely to otherwise receive treatment. This figure represents care you provided knowing the individual(s) were unable to pay. $100 to $1,000 per year Please indicate for 2009
$ 1,001 to $2,500 per year	$ 1,001 to $2,500 per year Please indicate for 2009
$ 2,501 to $5,000 per year	$ 2,501 to $5,000 per year Please indicate for 2009
$ 5,001 to $10,000 per year	$ 5,001 to $10,000 per year Please indicate for 2009
$ $10,000 per year	$ $10,000 per year Please indicate for 2009
I do not provide free treatment at my office	I do not provide free treatment at my office Please indicate for 2009

Comments

2. Please provide an estimate of the number of HOURS you provide to staff clinics or offices that provide free or reduced fee services (i.e., Creighton's Dental Clinic, OneWorld Dental Clinic, Mission of Mercy, GKAS Day at the Douglas County Dental Clinic, or other)

Please provide an estimate of the number of HOURS you provide to staff clinics or offices that provide free or reduced fee services (i.e., Creighton's Dental Clinic, OneWorld Dental Clinic, Mission of Mercy, GKAS Day at the Douglas County Dental Clinic, or other) I do not donate time to other dental offices or services

I donate between 1 and 5 hours per WEEK

I donate between 1 and 5 hours per MONTH

I donate between 10 and 20 hours per QUARTER

I donate more than 80 hours per YEAR

Other (please specify)

3. Please indicate any community service provided by your office

Please indicate any community service provided by your office We collect candy at Halloween

We collect canned goods or other items for local charities

We provide free dental items to organizations that request them (i.e., toothbrushes, floss, etc.)

We provide education to area schools when requested

We donate a specific day to treating the less fortunate

Other (please specify)

4. Please circle your response to the following questions

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	N/A
My time is too valuable to give away	*Please circle your response to the following questions My time is too valuable to give away Strongly agree	My time is too valuable to give away Agree	My time is too valuable to give away Neither agree nor disagree	My time is too valuable to give away Disagree	My time is too valuable to give away Strongly disagree	My time is too valuable to give away N/A
I think all patients should pay for any services they receive	I think all patients should pay for any services they receive Strongly agree	I think all patients should pay for any services they receive Agree	I think all patients should pay for any services they receive Neither agree nor disagree	I think all patients should pay for any services they receive Disagree	I think all patients should pay for any services they receive Strongly disagree	I think all patients should pay for any services they receive N/A
I don't know how to get involved in providing dental care to the less fortunate	I don't know how to get involved in providing dental care to the less fortunate Strongly agree	I don't know how to get involved in providing dental care to the less fortunate Agree	I don't know how to get involved in providing dental care to the less fortunate Neither agree nor disagree	I don't know how to get involved in providing dental care to the less fortunate Disagree	I don't know how to get involved in providing dental care to the less fortunate Strongly disagree	I don't know how to get involved in providing dental care to the less fortunate N/A
I support other community organizations and prefer to volunteer outside of dentistry	I support other community organizations and prefer to volunteer outside of dentistry Strongly agree	I support other community organizations and prefer to volunteer outside of dentistry Agree	I support other community organizations and prefer to volunteer outside of dentistry Neither agree nor disagree	I support other community organizations and prefer to volunteer outside of dentistry Disagree	I support other community organizations and prefer to volunteer outside of dentistry Strongly disagree	I support other community organizations and prefer to volunteer outside of dentistry N/A
I prefer to keep my community involvement to myself	I prefer to keep my community involvement to myself Strongly agree	I prefer to keep my community involvement to myself Agree	I prefer to keep my community involvement to myself Neither agree nor disagree	I prefer to keep my community involvement to myself Disagree	I prefer to keep my community involvement to myself Strongly disagree	I prefer to keep my community involvement to myself N/A
I would provide more charitable care if I were asked personally on a case-by-case basis	I would provide more charitable care if I were asked personally on a case-by-case basis Strongly agree	I would provide more charitable care if I were asked personally on a case-by-case basis Agree	I would provide more charitable care if I were asked personally on a case-by-case basis Neither agree nor disagree	I would provide more charitable care if I were asked personally on a case-by-case basis Disagree	I would provide more charitable care if I were asked personally on a case-by-case basis Strongly disagree	I would provide more charitable care if I were asked personally on a case-by-case basis N/A

Other (please specify)

5. Please indicate what kind of volunteer work you are involved with OUTSIDE of dentistry

Please indicate what kind of volunteer work you are involved with OUTSIDE of dentistry Church

My kids' school

My kids' sports

My study group

A nonprofit arts organization

A nonprofit civic group (Kiwanis, Lyons Club, etc)

Alumni Organization

A nonprofit community organization (neighborhood, historical, non-health care-related, etc)

A nonprofit community organization that is health-related (Cancer Society, Alzheimer's, Cystic Fibrosis, etc.)

Other (please specify)

Community Dentistry Initiative 2010 Survey
Exit this survey

1. Estimate Charitable Services Donated

1. Please provide an estimate of the value of the dentistry you provide each year at your office to individuals who would not be likely to otherwise receive treatment. This figure represents care you provided knowing the individual(s) were unable to pay.

2. Please provide an estimate of the number of HOURS you provide to staff clinics or offices that provide free or reduced fee services (i.e., Creighton's Dental Clinic, OneWorld Dental Clinic, Mission of Mercy, GKAS Day at the Douglas County Dental Clinic, or other)

3. Please indicate any community service provided by your office

4. Please circle your response to the following questions

5. Please indicate what kind of volunteer work you are involved with OUTSIDE of dentistry

Community Dentistry Initiative 2010 SurveyExit this survey

1. Estimate Charitable Services Donated

1. Please provide an estimate of the value of the dentistry you provide each year at your office to individuals who would not be likely to otherwise receive treatment. This figure represents care you provided knowing the individual(s) were unable to pay.

2. Please provide an estimate of the number of HOURS you provide to staff clinics or offices that provide free or reduced fee services (i.e., Creighton's Dental Clinic, OneWorld Dental Clinic, Mission of Mercy, GKAS Day at the Douglas County Dental Clinic, or other)

3. Please indicate any community service provided by your office

4. Please circle your response to the following questions

5. Please indicate what kind of volunteer work you are involved with OUTSIDE of dentistry

Community Dentistry Initiative 2010 Survey
Exit this survey