Dental Health Survey in Nebraska

1. Demographics

Thank you for participating. The information you supply regarding your child/children’s dental health care will assist in planning for improvement regarding dental services for children with special health care needs and disabilities.

All information is confidential.

The survey references to children means children of any age and who have special health care needs or a disability.

1. We live in

We live in Eastern Nebraska

Central Nebraska

Northern Nebraska

Western Nebraska

2. The distance traveled to our dentist

The distance traveled to our dentist 50 miles or fewer

50 to 100 miles

100 to 200 miles

200 to 300 miles +

3. Children’s Ages

Children’s Ages

4. Children’s disability or health care need

Children’s disability or health care need