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Research Study Interest Form_Dental CQ

Dental Care Research Study Sign Up

Thank you for your interest in participating in a one-on-one interview with a team member at the Indiana Community Action Poverty Institute! We regularly interview Hoosiers to better understand the challenges and barriers they are facing so that we can influence policies and programs to improve lives.

We truly appreciate your willingness to share your experiences and thoughts with us!

This sign up form is for our research study on dental care access and dental care debt. This study is funded by CareQuest Institute for Oral Health.
1.Please let us know how to get in touch with you!(Required.)
2.Your Zip Code:
3.Your age range:
4.Which time of day is best for you?(Required.)
5.This study is about dental care and financial challenges affording dental care. What are things you want to be sure to share with the interviewer?(Required.)
6.Are any of the following true for you?
7.Do you currently have dental insurance?
8.How else would you like to engage with us?
Current Progress,
0 of 8 answered