NDDA Volunteer Survey - Dental Assistants

SECTION ONE: Introduction

As oral health professionals there are many opportunities for service in our state. We know the importance of good oral health and many are already providing care to those in need including volunteering.

The North Dakota Dental Association (NDDA) is organizing a network of dental professionals interested in volunteering or contracting and linking them with non-profit clinics or sites. Note: Dental hygienists or assistants can work with or without their current employer dentist.

Be assured by completing this survey you are only indicating your interest in donating or contracting services, it does not obligate you to volunteer or contract for services. A representative of NDDA will contact you to follow-up and discuss your selections.

If you would like to speak with someone from the NDDA regarding this initiative please call 800-795-8870 or email assist.ndda@midconetwork.com.

SECTION TWO: Your Interest

As dental professionals, there is not greater benefit from our skills than to serve those who have barriers to oral health care. Won’t you consider helping in your own way on your own terms?

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* Please indicate (Check one).

I am interested in volunteering only.

I am interested in contract for service work only.

I am interested in volunteer and contract for service work.

I am not interested at this time.

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* SECTION THREE: Your Preferences

I would prefer to serve in the following clinic/sites (Check all that apply):

Tribally Based Sites (IHS – Indian Health Service is a federal agency within the Department of Health and Human Services responsible for providing health care to eligible American Indians.):

IHS, Belcourt, Turtle Mountain Reservation - Rolette County

IHS, Fort Totten, Fort Totten Reservation - Benson County

IHS, Fort Yates, Standing Rock Reservation - Sioux County

IHS, Trenton, Trenton Service Area - Williams County

Tribal Clinic, New Town, Fort Berthold Reservation - McKenzie County

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* Non-Profit Safety Net Sites (Check all that apply):

Bridging the Dental Gap, Bismarck

Family HealthCare, Fargo

Northland Community Health Center, Turtle Lake - McLean County/Minot

Valley Community Health Centers Dental Clinic, Grand Forks

Other (please specify)

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* Other (Check all that apply):

Mission of Mercy Events (2-day portable clinic)

Ronald McDonald Care Mobile, (mobile dental van, based out of Bismarck)

Anywhere there is a need

Other (please specify)

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* I would prefer the following schedule (Check all that apply):

A couple of days at a time

A couple of weeks at a time

Regular weekly schedule

Regular monthly schedule

Once a year

As needed for a designated period of time

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* SECTION FOUR: Your Area(s) of Expertise

Degree or Registration

Specialty

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* SECTION FIVE: Your Contact Information

By submitting this Survey I certify that I am currently licensed or registered in North Dakota in good standing and that I have professional liability coverage or am covered under my current employer’s coverage.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* Please indicate (Check one).

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* Non-Profit Safety Net Sites (Check all that apply):

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* Other (Check all that apply):

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* I would prefer the following schedule (Check all that apply):

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* SECTION FOUR: Your Area(s) of Expertise

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* SECTION FIVE: Your Contact InformationBy submitting this Survey I certify that I am currently licensed or registered in North Dakota in good standing and that I have professional liability coverage or am covered under my current employer’s coverage.

* SECTION FIVE: Your Contact Information

By submitting this Survey I certify that I am currently licensed or registered in North Dakota in good standing and that I have professional liability coverage or am covered under my current employer’s coverage.