EscaRosa Affiliate Needs Survey

The results of this survey will help EscaRosa Smiles with critical planning and grants for additional funding. No personally identifiable information will be shared with anyone. The survey should take approximately 3-5 minutes. The survey will be closed for further comments after 30 days.

Organization Name:

Contact Name:

Contact Title:

Contact Email:

Contact Phone:

During the past year (January 1, 2021 – December 30, 2021), how many 18+ females participated in your program?

Enter a number.

Out of the total number of females in your program, approximately what percentage would take advantage of free dental services?

Enter a percentage, 1 through 100.

In your opinion, what percentage of the total number of females in your program may need immediate care for dental problems?

Enter a percentage, 1 through 100.

On a scale of 1 to 10, what difference do you think free dental services could make on the success of your program and the success of your participants?

1 being the lowest, 10 being the highest.

Please explain what impact do you think free dental services could make on the success of your program and the success of your participants?

What types of barriers do you foresee for female applicants to receive dental services?:

CHOOSE ALL THAT APPLY TO YOUR CLIENTS.

Rank the following from 1 to 10 with 0 indicating no impact:

Transportation

Choose a rank, 1 through 10.

Child Care

Choose a rank, 1 through 10.

Scheduling

Choose a rank, 1 through 10.

Not able to pay a $15.00 application fee?

Choose a rank, 1 through 10.

Commitment to complete treatment?

Choose a rank, 1 through 10.

Anxiety About Dental Services?

Choose a rank, 1 through 10.

OTHER, explain below.

Choose a rank, 1 through 10.

If OTHER, please explain below...

I HAVE ADDITIONAL QUESTIONS (Please choose from dropdown box below.)

EscaRosa Affiliate Needs Survey

EscaRosa Affiliate Needs Survey

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