CA-OPEN Sign-Up Survey

Thank you for signing up for CA-OPEN emails. So that we can have a better sense of your interests, please complete the following demographic survey. Thank you.

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* 1. What is your name?

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* 2. Organization name? (if applicable)

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* 3. Title? (if applicable)

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* 4. Email?

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* 5. City?

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* 6. What is your language preference?

English

Spanish

Madarin

Cantonese

Korean

Japanese

Other (please specify)

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* 7. Type of organization/affiliation (if applicable)? Check all that apply:

Non-profit organization

County government

State government

School supports and services

Social services organization

Community clinic

Private practice - Dental

Private practice - Medical

Private practice - Behavioral health

Hospital

Health plan

Dental plan

Legal aid organization

Foundation

Media company

Advocacy or public policy organization

No affiliation

Other (please specify)

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* 8. Populations/communities served by you/your organization:

Children

Adults

Seniors

Pregnancy

Current or former foster children and youth

African American

Latinx

Asian American

Pacific Islander

Indigenous

Native American

Alaskan Native

LGBTQIA2S

Adults with disabilities

Children with disabilities

People with substance use disorders

Low-income people

Immigrant communities (please specify)

Refugees

People with limited English proficiency (preferred language other than English)

Providers (please specify)

Policy makers

Other (please specify) or additional details

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* 9. What are the language capacities of your organization?

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* 10. Region of the state you/your organization serves:

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* 11. CA OPEN has four active forums (work groups) to discuss policy, networking, and other activities and events to support oral health equity work. As we work to make these forums more interactive to our members, please let us know which ones you could be most interested in participating in:

Policy: meets quarterly to discuss policy opportunities, recommend policy priorities for the year; and identify policy advocacy opportunities to share with the network.

Communications and Engagement: meeting monthly to review communication needs, develop and disseminate network messages and materials, and identifies training, capacity building, and networking opportunities for members.

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* 12. We are seeking new ideas and opportunities to align and connect members, which activities would you be most interested in participating in:

Policy and advocacy updates: getting information about federal, state or local policy movements or actions by policymakers and opportunities to weigh in.

Policy and advocacy opportunities: timely opportunities to weigh in on policy issues at the federal, state, and local levels including ways to send letters of support; provide testimony; opportunities to sign on to letters of support/opposition; or ways to contact representatives about a policy issue.

Online training and capacity building on various oral health and advocacy issues

Opportunities to network and collaborate on projects including events and presentations

Submitting oral health tools and resources to the webpage

Submitting nominations or participating in opportunities to highlight members or leaders in oral health to our online newsletter

Convening an event at the local, regional or statewide level

Participating in or getting information about local oral health efforts, events, and information

Participating in or getting information about statewide efforts, events, and information

Other (what other ideas do you have to engage members):