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?

* Please indicate (Check one).

* 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.):

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

* Other (Check all that apply):

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

* SECTION FOUR: Your Area(s) of Expertise

* 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.

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