Questionnaire for Dental Professionals Serving Special Needs Populations

2-1-1 First Call For Help needs your assistance in finding dentists and medical professionals in our immediate community that serve children (birth-22) with special needs and developmental disabilities (e.g. Autism, Cerebral Palsy, visual or hearing impairments). The goal is to create an information and referral database for parents and providers in Broward County who require specialized accommodations and treatments for a child with special needs. If you choose to complete this survey, you must also input your name, title, and principle site address in order to be included in this information and referral database, which is at no charge. By taking a moment to complete this survey, you will be helping to identify appropriate referrals for the special needs community in Broward County. We sincerely thank you for your time and consideration.

Your Name:

__________________ ______________________ ___________

First, Last, Title

Please list your principal office in Broward County:

__________________________________________

Phone: ____________________________________

1. Do you have a specialization related to assisting the developmentally disabled?

(please specify) ___________________________

2. Which age group(s) do you see consistently on your site? (Check all that apply)

Newborns / Infants with Disabilities

Children with Disabilities

Adolescents with Disabilities

Others (please specify) ________________________

3. Approximately what percentage of your practice, in a 12-month period, consisted of serving

children with special (health care) needs? _____%

4. Please identify any specialization / trainings that you or your medical team has:_____________

Autism Cerebral Palsy Visual Impairments Hearing Impairments Mental Retardation

Other(s):______________________________________________________________________

Accessibility

5. Are you willing to reasonably extend a scheduled appointment (or currently do so) when seeing

a child with special needs at your office?

Yes No

Additional Comments:__________________________________________________________

6. Is the patient site fully accessible to the disabled population?

Yes No

Additional Comments:__________________________________________________________

Coordination

7. Would your office consider contacting the school regarding a child’shealth and education

needs, as part of care coordination (or do you currently perform this type of communication)?

Yes No

Additional Comments:___________________________________________________________

8. Are you knowledgeable about resources (direct or indirect: e.g., federal, state, local,

foundations, clubs, non-governmental agencies) available to families of special needs children?

Yes No

Additional Comments:____________________________________________________________

9. Would you be comfortable working in a medical-team situation with other professionals who may also be seeing the child with special needs?

Yes No

Additional Comments:____________________________________________________________

10. Is there a designated dentist who sees your patients when you are unavailable?

Yes No Additional Comments:____________________________________________________________

11. Would there be any additional charges for a supplemental staff member to assist with a child having special needs?

Yes No

Additional Comments:____________________________________________________________

12. Would you be interested in more information (i.e. hand-outs, newsletters, or attending

workshop) on the topic of adequately serving the disabled population for your practice?

Yes No

Additional Comments:____________________________________________________________

13. What do you see as being the major obstacle(s) to providing effective care to children with

special needs?

Comments:_____________________________________________________________________

______________________________________________________________________________

Thank you for completing this survey.

Please either return by mail to: Special Needs Manager, 2-1-1 First Call For Help of Broward
3217 NW 10^th Terrace, Suite 307, Fort Lauderdale, FL 33309

or fax to (954) 390-0499

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