Aug 26, 2010

Mobile Dental Clinic Survey

A mobile dental clinic provides local, community access to preventative dental services for children and adults who may be unable to get to a dentist's office. A mobile dental clinic is a dentist's office that is inside a fully accessible Recreational Vehicle (RV) or bus that has a dentist and trained staff to provide dental care. The Agency for Persons with Disabilities, the Florida Developmental Disabilities Council, The Family Care Council, and the Arc of Florida are seeking input on a proposed Mobile Dental Clinic. Please answer the following questions to help us determine your interest in this project.

The deadline to complete this survey is August 31, 2010. Please submit your response via fax to (850) 922-6702 or via email to . This survey is also available online at

1) I would visit a mobile dental clinic in my community in order to receive preventative dental care.
______ Yes

______ Maybe

______ No

2) The dental services that I would like to or would need to receive at a mobile dental clinic are (select all that apply):
______ Oral health (mouth) screenings

______ X-rays

______ Teeth cleaning

______ Fluoride varnish/teeth sealants

______ Tooth fillings

______ Tooth extractions

______ Other (Please specify) ________________________

3) If you use a wheelchair, would you require help from others to move from a wheelchair to a dental chair?

______ Yes

______ No

______ Does not apply to me

4) If you use a wheelchair, would you be able to move (with or without help) to a dental chair to receive care?

______ Yes

______ No

______ Does not apply to me

5) Has a doctor or dentist ever told you that you need antibiotics or sedation (like Valium or Ativan) before receiving dental care?

______ Yes

______ No

______ I'm not sure

6) If a mobile dental clinic were to provide services at a public location in your community, what days of the week would you be most likely to visit the mobile dental clinic? Select all days that apply:
______ Monday

______ Tuesday

______ Wednesday

______ Thursday

______ Friday

______ Saturday

______ Sunday

7) How many times have you been to a dentist in the past 3 years?

______ 0

______ 1-2

______ 3-4

______ 5 or more times

8) Do you receive any of the following Agency for Persons with Disabilities (APD) services?

______ I am on the waiting list for APD services

______ I am not on the waiting list or do not wish to receive APD services

______ I am on Tier 1, 2, or 3 of the Home and Community Based Services (HCBS)
______ I am on Tier 4 of the Home and Community Based Services (HCBS) Waiver

______ I am in "TBD" status (I do not have a tier assignment or I have requested a
hearing regarding my tier assignment)

9) In which county do you live? _____________

10) Please feel free to share your comments in the space below:

Thank you very much for your time and your responses. Your input is valuable and appreciated